2017 Benefit Structure
Historically, generic medications were typically the lowest-cost option for prescription medications. This is no longer true for all medications in today’s rapidly changing marketplace. As a result of this trend, Navitus has organized the formulary in a way that focuses more on value and less on generic vs. brand delineations. The tiers on the formulary are structured as follows:
- Tier 0: Certain preventative medications.
- Tier 1: Low-cost, high-value generics and select brands that provide high clinical value. These products are the lowest-net cost for the plan and the lowest copayment for the member.
- Tier 2: Preferred brands and select generics that are less cost effective.
- Tier 3: Non-preferred brands and generics that provide the least value because of high cost or low clinical value, or both.
Prescription Max Out-of-Pocket: Individual $1,800 / Family $3,600
| Benefit Structure
|
Retail Network Pharmacy (30 Day Supply)
|
Retail Out-of-Network Pharmacy (10 Day Supply)
|
Retail or Mail Order Network Pharmacy (90 Day Supply)
|
Applies to Prescription Max Out-of-Pocket
|
| Tier $0 - Certain preventive medications*
|
$0 copayment
|
$0 copayment
|
$0 copayment
|
Yes
|
| Tier 1 - Preferred generics and some lower cost brand products
|
$15 copayment
|
$15 copayment
|
$30 copayment
|
Yes
|
| Tier 2 - Preferred brand products and some high cost non-preferred generics
|
$50 copayment
|
$50 copayment
|
$100 copayment
|
Yes
|
| Tier 3 - Non-preferred products (may include some high cost non-preferred generics)
|
50% coinsurance
|
50% coinsurance
|
50% coinsurance
|
No
|
*These preventive medications will be noted on the Formulary.
Specialty Benefits
| Benefit Structure
|
Preferred Specialty Pharmacy (30 Day Supply)
|
Retail Network Pharmacy - Includes Non-preferred Specialty Pharmacies (30 Day Supply)
|
Retail Out-of-Network Pharmacy
|
Network Mail Order Pharmacy (90 Day Supply)
|
Applies to Prescription Max Out-of-Pocket
|
| Tier 4 - Specialty Drugs
|
$200 copayment
|
50% coinsurance
|
50% coinsurance
|
N/A
|
Only if filled at Preferred Specialty Pharmacy
|