Prescriptions related to COVID-19 treatment are covered according to your regular plan benefits. For more information, log on to the Navitus member portal or call Navitus Customer Care at (855) 673-6504.
On January 1, 2022, Navitus Health Solutions replaced Anthem IngenioRx as the administrator of the UC PPO plans prescription drug benefit. Read more about this change.
How the Plan Works What's Covered and What You Pay Formulary Changes Filling Prescriptions Money-Saving Options Restrictions and Rules
How the Plan Works
Prescription drugs are managed by Navitus Health Solutions (Navitus). Sign in to the Navitus member portal to access a variety of tools that include viewing what’s covered by the Navitus formulary, previewing drug costs, and finding pharmacies near you.
What’s Covered and What You Pay
What’s Covered
The formulary, or preferred drug list, is a list of drugs that are covered under the plan. Medications on the list are grouped into four tiers.
- Tier 1: Preferred generics and some lower-cost brand-name products.
- Tier 2: Preferred brand-name products and some high-cost non-preferred generics.
- Tier 3: Non-preferred products (could include some high-cost non-preferred generics).
- Tier 4: Specialty drugs used to treat complex chronic conditions.
For questions about what’s covered and your costs, call Navitus Customer Care at (855) 673-6504, available 24 hours a day, 7 days a week, except Thanksgiving and Christmas Day.
What You Pay
|
In-Network UC Pharmacies & Participating Navitus Pharmacies |
Out-of-Network Non-Participating Pharmacies |
|
|---|---|---|
|
Calendar-Year Deductible (combined with medical/behavioral health out-of-pocket expenses) |
Individual: $1,400 |
Individual: $2,550 |
|
Out-of-Pocket Maximum (includes pharmacy, medical and behavioral health out-of-pocket expenses) The most you’ll pay for covered services in a calendar year. |
Individual: $4,000 |
Individual: $8,000 |
|
Contraceptive Drugs and Devices |
No charge | Not covered |
|
Tier 1: Preferred Generic |
After deductible: |
After deductible: |
| Tier 2: Preferred Brand |
After deductible: |
After deductible: |
| Tier 3: Non-Preferred |
After deductible: |
After deductible: |
| Tier 4: Specialty | After deductible: Lumicera and select UC pharmacies (30-day supply): 20% ($200 out-of-pocket maximum per prescription for oral anti-cancer medications only) |
Not covered |
| Smoking Cessation: Over-the-Counter and Prescription Drugs (prescription required) | Retail (30-day supply): No charge | Not covered |
| Diabetic Supplies (excluding syringes, needles and non-formulary test strips) | After deductible: Retail (30-day supply): No charge |
Not covered |
Formulary Changes
Occasionally, the formulary is updated periodically. Updates are shown below.
See the 2022 Formulary for more details about your Medicare and Navitus prescription drug coverage.
2022
April
| Drug Name | Change Type |
|---|---|
| progesterone cap | Change to Tier 1 |
| desvenlafaxine ER tab | Change to Tier 1 |
| silodosin cap | Change to Tier 1 |
| diclofenac gel | Change to Tier 2 |
| XARELTO SUSP | Add to Tier 2 |
| OXBRYTA TAB | Add to Tier 4, Prior Authorization required |
| KERENDIA TAB | Add to Tier 3, Prior Authorization required |
| BYLVAY CAP 400MCG | Add to Tier 4, Prior Authorization required |
| BYLVAY CAP 1200MCG | Add to Tier 4, Prior Authorization required |
| BYLVAY SPRINKLE CAP 200MCG | Add to Tier 4, Prior Authorization required |
| BYLVAY SPRINKLE CAP 600MCG | Add to Tier 4, Prior Authorization required |
| WELIREG TAB | Add to Tier 4, Prior Authorization required |
| OPZELURA CREAM | Add to Tier 3, Prior Authorization required |
| EXKIVITY CAP | Add to Tier 4, Prior Authorization required |
| AJOVY INJ | Add to Tier 2, Prior Authorization required |
| NURTEC ODT | Change to Not Covered |
| WEGOVY INJ | Add to Tier 2, Prior Authorization required |
| SAXENDA INJ | Add to Tier 2, Prior Authorization required |
Filling Prescriptions
Retail Pharmacies
You can fill up to a 90-day supply through the Navitus national network of retail pharmacies, which includes Costco, CVS, Walgreens, Walmart, Safeway/Vons and more. Sign in to the Navitus member portal to view the full list of network pharmacies and find one near you.
UCMC Pharmacies
Prescription drug fills and refills are available at many UC Medical Center pharmacies [PDF].
Mail-Order
Get up to a 90-day supply of medication without leaving home. Use the Costco Mail Order Pharmacy for maintenance medications, such as those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure and high cholesterol. Home delivery makes it quick and convenient. Start a new prescription and request refills online or use the mail order form [PDF], and your prescription will be delivered to you by mail. Learn more about how to order through mail order [PDF].
Specialty Medications
For prescription drugs used to treat complex conditions, Navitus MedicareRx offers members access to a specialty pharmacy, Lumicera Health Services. Ordering new prescriptions through Lumicera Health Services is simple, and you can get free delivery of specialty medications to your home or other locations. Just visit Lumicera online or call (855) 847-3553 to get started, or work with your provider to use select UC pharmacies.
Note: Specialty prescription medications administered in your doctor’s office (e.g., Botox) may be covered under your prescription drug benefit.
Money-Saving Options
Tablet Splitting
Tablet splitting is breaking a higher-strength drug tablet in half to deliver the same prescribed dose as a full tablet. This means you get the exact same drug and dosage, but you save money by paying for fewer tablets. For medications that can easily be cut in half without compromising efficacy, you can save up to 50% on out-of-pocket costs for select medications by having your doctor write a prescription for double the strength (e.g., 20 mg instead of 10 mg) and simply splitting the tablets in half.
Specialty Split Fill
Specialty medications are often expensive and can include side effects, which can cause people to stop taking the drug or modify their dosage. This program gives you time to discover whether a certain class of drugs will work for you, without wasting money on unused medications or risking complications caused by discontinued use. Here’s how it works: When you receive a 30-day prescription, you’ll receive one 15-day supply at a prorated cost. This gives you two weeks to see how well you tolerate the drug or to talk to your doctor about switching to a different medication.
Restrictions and Rules
Brand Name Drug Penalty May Apply
When a generic drug is available and you or your physician choose the brand-name drug, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. If a prior authorization is approved for a medical necessity exception, you will pay the Tier 3 (non-preferred) cost.
Prior Authorization
Some drugs, and certain amounts of some drugs, require an approval by Navitus before they can be filled. Generally, your doctor must show that a particular drug is medically necessary. Learn more about prior authorization.
Quantity Limits
Taking too much medication or using it too often isn’t safe and may even increase your costs. If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, the Navitus pharmacy system will reject your claim. If your doctor believes your situation requires an exception, the doctor can contact Navitus to request prior authorization review.
Step Therapy
If your doctor prescribes a more expensive drug when a lower-cost alternative is available, you may be required to first try the less expensive drug that’s been proven to be effective — before you can “step” up to the more expensive medication. Drugs that require step therapy include those used to treat ADHD, diabetes, high cholesterol and multiple sclerosis.