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.
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 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.
About the Formulary
What to Know About the Formulary
A formulary is an extensive list of safe, effective medications covered by a health plan. Every pharmacy benefit manager (Navitus, for the UC PPO plans) uses its own formulary and it changes over time as new drugs enter the market and brand-name patents expire, etc. Generally, if drugs aren’t on the formulary, they aren’t covered by the plan.
The Navitus formulary is divided into 4-tiers. The lowest cost drugs (mostly generic) are in Tier 1. The highest cost medications are in Tier 4 (specialty).
What does this look like?
Say you are newly diagnosed with high blood pressure and your doctor prescribes Atenolol to treat it. A quick scan of the formulary shows Atenolol is a generic equivalent for the brand-name drug Tenoretic. It also classifies Atenolol as a Tier 1 medication, so you know what you’ll pay.
The formulary also will show if any restrictions and rules apply, such as prior authorization, quantity limits or step therapy.
When filling a Prescription
Find out if the drug is covered first. A quick search of the Navitus formulary will tell you. Download the Navitusplus app to have the formulary with you at the doctor’s office. If the drug the doctor recommends isn’t listed, you can look for alternatives in real time. If you don’t see the drug on the formulary, you or your doctor can contact Navitus Customer Care at (855) 673-6504 for help.
If there’s a generic version of a drug you are prescribed and you choose the brand-name drug instead, you’ll pay a penalty.
Formulary Updates
Occasionally, the formulary is updated. Updates are shown below.
See the 2022 Formulary for more details about your Medicare and Navitus prescription drug coverage.
October
ROZEREM TAB | Add to Tier 3 |
ramelteon tab | Add to Tier 2 |
SONATA CAP | Add Quantity Limit |
zaleplon cap | Add Quantity Limit |
XIFAXAN TAB 550MG | Add Quantity Limit |
FREESTYLE LIBRE 3 SENSOR | Add to Tier 3 |
OLUMIANT TAB 4MG | Add to Specialty Tier |
PHOSPHOLINE OPHTH SOLN | Move to Not Covered |
LIVTENCITY TAB | Add to Specialty Tier |
VONJO CAP | Add to Specialty Tier |
PYRUKYND TAB | Add to Specialty Tier |
PYRUKYND TAPER PACK | Add to Specialty Tier |
MOUNJARO INJ | Add to Tier 2, Restricted to Diagnosis |
BYDUREON BCISE AUTO INJ | Add Restricted to Diagnosis |
BYDUREON INJ | Add Restricted to Diagnosis |
BYDUREON PEN INJ | Add Restricted to Diagnosis |
BYETTA INJ | Add Restricted to Diagnosis |
OZEMPIC INJ | Add Restricted to Diagnosis |
RYBELSUS TAB | Add Restricted to Diagnosis |
TRULICITY INJ | Add Restricted to Diagnosis |
VICTOZA INJ | Add Restricted to Diagnosis |
ADBRY INJ | Add to Specialty Tier |
CIBINQO TAB | Add to Specialty Tier |
September
DEPO-PROVERA INJ | Add to Tier 3 |
TOVIAZ TAB | Add to Tier 3 |
fesoterodine fumarate tab er | Add to Tier 2 |
PRALUENT INJ | Move to Not Covered |
posaconazole tab | Move to Tier 3 |
NOXAFIL SUSP | Move to Tier 3 |
voriconazole susp | Move to Tier 3 |
TYVASO DPI POWDER | Add to Specialty Tier |
TYVASO DPI POWDER MAINTENANCE KIT | Add to Specialty Tier |
TYVASO DPI POWDER TITRATION KIT | Add to Specialty Tier |
MELOXICAM SUSP | Move to Not Covered |
SKYRIZI INJ 360MG/2.4ML | Add to $0 |
August
EPOGEN INJ | Move to Not Covered |
ALKINDI SPRINKLE CAP 0.5MG, 1 MG | Add to Tier 3 |
armodafinil tab | Removed Prior Authorization |
NUVIGIL TAB | Removed Prior Authorization |
modafanil tab | Removed Prior Authorization |
PROVIGIL | Removed Prior Authorization |
LYVISPAH GRANULE PACKET | Add to Tier 3 |
VIJOICE TAB | Add to Specialty Tier |
VIJOICE TAB 250MG | Add to Specialty Tier |
ASPIRIN TAB 81MG | Delete from formulary, product discontinued |
aspirin tab 81mg | Delete from formulary, product discontinued |
aspirin tab 325mg | Move to Not Covered |
ASPIRIN EC TAB 325MG | Move to Not Covered |
aspirin chew tab 81mg | Move to $0, covered for females |
aspirin ec tab 81mg | Move to $0, covered for females |
June
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
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 |
What You Pay
UC Health Savings Account Contribution (use this to pay your initial expenses before you meet the deductible) | Individual coverage: $500 | Individual coverage: $500 |
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 |
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.