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Benefit Structure

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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