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
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Retail Network Pharmacy (30 Day Supply)
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Retail Out-of-Network Pharmacy (10 Day Supply)
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Retail or Mail Order Network Pharmacy (90 Day Supply)
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Applies to Prescription Max Out-of-Pocket
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Tier $0 - Certain preventive medications*
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$0 copayment
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$0 copayment
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$0 copayment
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Yes
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Tier 1 - Preferred generics and some lower cost brand products
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$15 copayment
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$15 copayment
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$30 copayment
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Yes
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Tier 2 - Preferred brand products and some high cost non-preferred generics
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$50 copayment
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$50 copayment
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$100 copayment
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Yes
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Tier 3 - Non-preferred products (may include some high cost non-preferred generics)
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50% coinsurance
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50% coinsurance
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50% coinsurance
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No
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*These preventive medications will be noted on the Formulary.
Specialty Benefits
Benefit Structure
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Preferred Specialty Pharmacy (30 Day Supply)
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Retail Network Pharmacy - Includes Non-preferred Specialty Pharmacies (30 Day Supply)
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Retail Out-of-Network Pharmacy
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Network Mail Order Pharmacy (90 Day Supply)
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Applies to Prescription Max Out-of-Pocket
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Tier 4 - Specialty Drugs
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$200 copayment
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50% coinsurance
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50% coinsurance
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N/A
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Only if filled at Preferred Specialty Pharmacy
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Effective January 1, 2018, Medicare Retirees enrolled in the Navitus MedicareRx plan will have a $50 copayment for Specialty Medications when filling at the Preferred Specialty Pharmacy.