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Pharmacy

Navitus Health Solutions is the administrator of the UC PPO plans prescription drug benefit.

How the Plan Works What's Covered and What You Pay Filling Prescriptions Diabetic Supplies Money-Saving Options Getting Help

How the Plan Works

Your medical coverage includes Medicare Part D drug benefits and non-Medicare supplemental drug benefits.

Because this is a Medicare Part D plan, the Navitus MedicareRx prescription drug plan (PDP) is required to track and notify you of your Part D drug costs, the amount you pay out of pocket, and your current coverage level or “stage.” For each month that you obtain Part D prescription drugs, you will be mailed an Explanation of Benefits (EOB) that outlines the information. This is for tracking purposes only. The EOB is not a bill.

Pharmacy benefits are administered by Navitus Health Solutions (Navitus). Sign in to the Navitus member portal to access a variety of tools that include viewing the Navitus MedicareRx formulary, finding local in-network pharmacies and low-cost medication options, and getting forms and information about home delivery. In general, there is no coverage for out-of-network pharmacies.

What’s Covered and What You Pay

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 MedicareRx Customer Care at (866) 270-3877.

The plan covers generic and brand-name drugs, including high-cost specialty drugs, which goes beyond the minimum standard that Medicare requires.

Your prescription drug benefit includes coverage for medications on the Part D formulary, plus hundreds of additional drugs not normally covered by Medicare Part D. Medications on the list are grouped into four tiers.

  • Tier $0: Select generics (not all dosages of these drugs are covered at the “select generics” cost share) and certain over-the-counter drugs. See the Evidence of Coverage [PDF] booklet for details.
  • 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 MedicareRx Customer Care toll-free at (866) 270-3877, available 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day. TTY users can call 711.

What You Pay

Drugs Covered by Medicare Part D

 

UC Pharmacies & Participating Navitus MedicareRx Pharmacies

Deductible

None

Out-of-pocket Maximum

None

True Out-of-Pocket Maximum (TrOOP)

The most you'll pay for covered Medicare Part D prescriptions in a calendar year.

$7,0501
Retail Network Pharmacies (30-day supply)

Tier 1 (Preferred Generic): $10
Tier 2 (Preferred Brand): $30
Tier 3 (Non-Preferred): $45
Tier 4 (Specialty): $30

UC Pharmacies and Select Retail Pharmacies — CVS, Walgreens, Costco, Safeway/Vons and Walmart (90-day supply)

Tier 1 (Preferred Generic): $20 
Tier 2 (Preferred Brand): $60 
Tier 3 (Non-Preferred): $90
Tier 4 (Specialty): $60 (long-term supply not available for specialty drugs)

Retail Network Pharmacies (90-day supply)
Includes UC pharmacies and select retail pharmacies (CVS, Walgreens, Costco, Safeway/Vons and Walmart)

Tier 1 (Preferred Generic): $30 
Tier 2 (Preferred Brand): $90 
Tier 3 (Non-Preferred): $135
Tier 4 (Specialty): $90 (long-term supply not available for specialty drugs)

Mail Order (90-day supply)

Tier 1 (Preferred Generic): $20 
Tier 2 (Preferred Brand): $60
Tier 3 (Non-Preferred): $90
Tier 4 (Specialty): Not available

1. You continue to pay the cost of Extra Covered Drugs, even after the TrOOP is reached.

The benefit information provided is a summary of what is covered and what you pay. Your cost sharing may differ based on the pharmacy’s status as preferred/non-preferred; mail order; long-term care; home infusion; one-month or extended-day supplies; and when you enter another stage of the Medicare Part D benefit. For more information on the additional pharmacy-specific cost sharing, the phases of the benefit, or a complete description of benefits, please see the Evidence of Coverage [PDF] booklet or call Navitus MedicareRx Customer Care toll-free at (866) 270-3877. TTY users can call 711.

Select Generic Drugs

Affordable medication is one of the many things that adds to your long-term well-being and peace of mind. Your UC pharmacy benefits include no-cost generic drugs used to treat some of the most commonly prescribed conditions, including diabetes, hypertension and high cholesterol — with zero out‑of‑pocket expenses to you at any in-network retail or mail-order pharmacy. All select generics have proven track records for effectiveness and value.

The sample list below includes some commonly prescribed drugs. For a complete list, see the Navitus formulary on the Navitus member portal or call Navitus MedicareRx Customer Care toll-free at (866) 270-3877. TTY users can call 711.

 

Cardiovascular

Atenolol tablet
Atenolol/ chlorthalidone tablet
Benazepril hcl tablet
Benazepril hcl/ hydrochlorothiazide tablet
Bisoprolol/ hydrochlorothiazide tablet
Captopril tablet
Captopril/ hydrochlorothiazide tablet
Chlorthalidone tablet
Enalapril maleate tablet
Enalapril/ hydrochlorothiazide tablet

Hydrochlorothiazide capsule/tablet
Irbesartan tablet
Irbesartan/ hydrochlorothiazide tablet
Lisinopril tablet
Lisinopril/ hydrochlorothiazide tablet
Losartan potassium tablet
Losartan potassium/ hydrochlorothiazide tablet
Metoprolol tartrate tablet
Ramipril tablet
Valsartan tablet
Valsartan/ hydrochlorothiazide tablet

Cholesterol

Lovastatin tablet
Pravastatin sodium tablet
Simvastatin tablet

Diabetes

Glimepiride tablet
Glipizide ER tablet
Glipizide tablet
Glipizide/metformin hcl tablet
Metformin hcl ER tablet
Metformin hcl tablet

Osteoporosis

Alendronate sodium tablet

Extra Covered Drugs

These are drugs that are often excluded from Part D coverage but are covered by your UC pharmacy benefit. Coverage includes prescription medications for cough and cold, vitamins and minerals, and lifestyle drugs, including those used to treat erectile dysfunction (ED). Extra Covered Drugs do not count toward your True Out-of-Pocket expenses. For more information about what’s covered, see the formulary on the Navitus member portal.

What You Pay

Covered Drug You Pay

Prescription Cough and Cold,
Vitamins and Minerals, and
Lifestyle Drugs

Generic: Retail or mail-order copayment
Preferred Brand: Retail or mail-order copayment
Non-Preferred Brand: Retail or mail-order copayment

Contraceptive Devices (in California only) Prescription: $0 copayment

 

Non-Part D Diabetic Supplies You Pay
Lancets and Blood Sugar Diagnostics Prescription: $0 copayment
Glucometers Copayment or coinsurance per covered device

Filling Prescriptions

In general, only prescriptions purchased through the in-network pharmacies listed below are covered. If you are unable to use a network pharmacy, you can request reimbursement from Navitus MedicareRx. For details, call Navitus MedicareRx Customer Care toll-free at (866) 270-3877. TTY users can call 711.

Retail Pharmacies

You can fill up to a 30-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 complete list of network pharmacies and find a pharmacy near you.

UCMC Pharmacies

Prescription drug fills and refills are available at many UC Medical Center pharmacies [PDF].

Mail-Order Prescriptions

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.

Specialty prescription medications administered in your doctor’s office (e.g., Botox) may be covered under your medical benefit (through CVS Specialty Pharmacy), not your prescription drug benefit. If you’re having a specialty medication administered by your doctor, call Anthem Health Guide toll-free at (844) 437-0486 for information about actions you or your doctor needs to take.

Diabetic Supplies

Medicare Part B is your primary insurance for diabetic supplies. Your Anthem Medicare PPO plan includes coverage for diabetic supplies under the Navitus MedicareRx pharmacy benefit. However, when ordering your diabetic supplies, Medicare Part B must pay as primary before your UC pharmacy benefit plan will pay as secondary.

The secondary diabetic supplies coverage is through your Navitus WRAP/Extra Covered Drug (ECD) benefit, not the Part D benefit.

Knowing how your plan pays for diabetic supplies can help you talk with your doctor and your pharmacy, and help you get testing supplies in a timely manner.

How Medicare Part B Works

Find a Pharmacy that Can Bill Medicare Part B

Ask your pharmacist if they can bill Medicare Part B for diabetic supplies. Most pharmacy chains — excluding Costco — can bill Medicare Part B, but some independent pharmacies are unable to. If your current pharmacy cannot bill Medicare Part B, you’ll need to choose a different pharmacy for your diabetic supplies.

You can search for network pharmacies near you by registering (if you haven’t already done so) and logging in to the Navitus member portal. The pharmacy directory will have each phone number listed so you can easily call to confirm whether they can bill Medicare Part B.

Submit the Prescription for Your Diabetic Supplies

Once you have found a pharmacy that can bill Medicare Part B, your doctor can send the prescription for your diabetic supplies to the pharmacy, or you can ask your old pharmacy to transfer your order to the new pharmacy.

Ask the pharmacy to bill Medicare Part B first and then submit it to Navitus MedicareRx for secondary payment.

Medicare Supply Limits and Approval Process for Larger Quantities

Medicare limits how many diabetic supplies you can receive. If you use insulin, you can get 300 strips and lancets every three months. If you do not use insulin, you can get 100 strips and lancets every three months.

If you need more supplies, ask your doctor to call the Medicare “Medical Provider Line” through Noridian at (855) 609-9960. The provider line will help your doctor know what documentation is needed to support the request for the larger quantity. Your doctor will need to submit a statement that includes:

  • Your bloodwork readings that verify your diabetes diagnosis
  • An explanation for why larger quantities is required
  • Confirmation that you know how to test at home
  • Confirmation that you are seeing your provider every six months

Medicare reviews the documentation to determine whether the details submitted are sufficient and either approves or denies the prescription. Medicare review is typically only needed for the first prescription fill.

Your doctor will also need to send the prescription for the test strips to the pharmacy, once approved by Medicare (if approval is needed).

Your pharmacy will need to provide Medicare with your doctor’s statement, along with the prescription.

Questions?

Contact any of these resources for help:

  • Medicare: (800)-MEDICARE (800-633-4227); ask to speak with a Tier 2 claims representative
  • Navitus MedicareRx Customer Care: (866) 270-3877
  • Your UC Health Care Facilitator Program

Money-Saving Options

Preferred Generics

Save money when you choose therapeutically equivalent generic medications over more expensive brand-name drugs. When your physician prescribes a brand-name drug, ask if a generic equivalent is suitable for your condition. If a generic equivalent is available — and you or your doctor requests the brand-name instead — you’ll pay the applicable brand-name copay plus the difference between the cost of the brand-name drug and the generic equivalent.

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.

Getting Help

Call Navitus MedicareRx Customer Care toll-free at (866) 270-3877. TTY users can call 711. They can answer questions about whether your prescription drug is covered, the cost of your copayment, and the location of the nearest pharmacy. They are available 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day.