You are here

Pharmacy

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

No deductible

No deductible

Out-of-Pocket Maximum (includes pharmacy, medical and behavioral health out-of-pocket expenses)1

The most you’ll pay for covered services in a calendar year.

Individual: $6,100
Family: $9,700

Individual: $9,600
Family: $20,200

Contraceptive Drugs and Devices

Retail (30-day supply): $0
Mail order (up to a 90-day supply): $0
Retail (30-day supply): $0
Mail order: Not covered

Tier 1: Preferred Generic

Retail (30-day supply): $5
Mail order (up to a 90-day supply): $10

Retail (30-day supply): 50%
Mail order: Not covered

Tier 2: Preferred Brand

Retail (30-day supply): $25
Mail order (up to a 90-day supply): $50

Retail (30-day supply): 50%
Mail order: Not covered

Tier 3: Non-Preferred

Retail (30-day supply): $40
Mail order (up to a 90-day supply): $80

Retail (30-day supply): 50%
Mail order: Not covered

Tier 4: Specialty Lumicera and select UC pharmacies (30-day supply): 30% (up to $150 maximum per prescription) 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) Retail (30-day supply): No charge Not covered

1. In-network (Anthem Preferred and UC Select) medical, behavioral health and prescription drug out-of-pocket copayment maximums count toward each other. In-network and out-of-network medical copayment maximums are separate — what you pay toward one doesn’t count toward the other. Annual out-of-pocket maximums include deductibles, copays, coinsurance and prescription drugs.

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

June

Drug Name Change Type
lacosamide tab Remove quantity limits
OZOBAX SOLN, BACLOFEN SOLN Add to Tier 3
LOVENOX INJ Remove quantity limits
enoxaparin inj Remove quantity limits
BRILINTA TAB Move to Tier 2
FLUOXETINE TAB 60MG Add to Tier 3
fluoxetine tab 60mg Add to Tier 1
EC- NAPROSYN TAB 500MG Change to Not Covered
naproxen DR tab 500mg Change to Not Covered
NARCAN NASAL SPRAY Move to Tier 3
naloxone prefilled inj Remove quantity limits
ANNOVERA RING Add to Tier 3
BACLOTRA TAB Add to Tier 3
BEYAZ TAB Add to Tier 3
drospirenone/ethinyl estradiol/levomefolate tab Add to Tier 3
DEPO-PROVERA INJ Add to Tier 3
SAFYRAL TAB Add to Tier 3
drospirenone/ethinyl estradiol/levomefolate tab Add to Tier 3
TAYTULLA CAP Add to Tier 3
norethindrone ace-ethinyl estradiol-fe cap Add to Tier 3
NEXTELLIS TAB Add to Tier 3
TWIRLA PATCH Add to Tier 3
YAZ TAB, YASMIN 28 TAB Add to Tier 3

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 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.