Copayments and benefits

Your prescription drug benefit

Formulary

The formulary is the complete list of drugs eligible for coverage. Medications are listed by cost levels known as tiers. Tiers can include both name-brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA) or designated medical supplies.

Call Navitus at 833-354-2226 or visit www.navitus.com to learn the formulary status of a medication. The tier placement of a drug may be changed at any time.

Benefit administration

The prescription drug benefit is administered by Navitus Health Solutions. As the administrator for the prescription drug program, Navitus processes payments for claims, answers questions, and reviews appeals according to the plan’s provisions. Navitus has been delegated authority to, in its sole discretion, interpret plan provisions as well as facts and other information for claims and appeals for the prescription drug benefit. Navitus’s decisions on claims and appeals are final and binding. For the time limits on prescription drug benefit appeals administered by Navitus see your General Information SPD.

Preauthorization is required for certain medications, including but not limited to long-term maintenance or large-quantity medications, and some provider-administered medications, including high-cost or specialty medications administered in a physician’s office, outpatient facility, or home.

Certain medications require step therapy, which means you must use a preferred alternative medication to treat a condition before moving to another formulary medication.

For some classes of drugs, the benefit is limited by quantity per prescription in accordance with federal, state, and manufacturer guidelines. In addition, certain medications may be subject to age or gender limits.

If this is your first time using a medication, purchase a 30-day supply from a retail pharmacy.

If you need more than a 30-day supply, you may save money by purchasing the medication from the mail order pharmacy.

Common medications not covered:

• Drugs not approved by the Federal Drug Administration (FDA)
• Drugs to prevent or delay pregnancy that do not meet current medical criteria
• Dietary or nutritional products, including special diets for medical problems
• Medications used for sexual dysfunction
• Non-formulary medications
• Over-the-counter medications, except as provided for by the terms of the plan
• Products used to stimulate hair growth
• Vitamins, except prescribed prenatal and infant vitamins
• Weight-reduction aids

Medications that are not covered by the plan may be eligible for reimbursement through Flexible Spending.

For more information about the prescription drug benefit, call Navitus at 833-354-2226 or visit memberportal.navitus.com.

Pharmacies

Navitus has a network of retail pharmacies, a mail-order pharmacy program, and a specialty pharmacy. To find out whether a pharmacy is in this network, call Navitus at 833-354-2226 or visit memberportal.navitus.com. If you buy prescription drugs from an out-of-network pharmacy, you must pay the pharmacy’s price and then submit a claim form for reimbursement directly to Navitus. The claim will be reimbursed according to plan guidelines based on the plan’s allowable amount for that medication (not the price paid at the pharmacy) minus the applicable coinsurance that you would have paid. This means you will not be reimbursed for the difference between the discounted in-network pharmacy price and the out-of-network pharmacy price for a prescription.

Retail pharmacies typically provide up to a 30-day supply. Some medications may be subject to additional supply limits from Navitus.

Retail 90 pharmacies provide between 60 and 90 days’ supply. Not all medications are fillable as a retail 90 pharmacy order.

Mail order pharmacy is for supplies of 60 to 90 days. Costco Mail Order Pharmacy is the only in-network mail order pharmacy. There is no benefit for out-of-network mail order pharmacies. Not all medications are fillable as a mail order pharmacy order.

Specialty pharmacies are for designated specialty drugs (formulary tiers S1 and S2). Most specialty drugs require preauthorization. Specialty drugs are generally limited to a 30-day supply.

To be covered, outpatient specialty medications must be filled through a participating specialty pharmacy, which includes Lumicera Health Services and Navitus SpecialtyRx designated pharmacies.

These pharmacies may fill specialty medications in certain circumstances:

• Intermountain Healthcare Specialty Pharmacy when you are receiving treatment at an Intermountain Healthcare facility contracted with the plan
• University of Utah Specialty Pharmacy when you are receiving treatment at a University of Utah facility contracted with the plan
• Specialty pharmacies contracted with certain hemophilia treatment centers for applicable drugs

Prescription drug formulary exception

A formulary exception request is needed when a participant’s provider requests coverage of a prescription drug not in the formulary.

An exception request must meet a medical necessity review by Navitus. If a non-formulary medication is approved for a coverage exception it is covered at Tier 3 for non-specialty drugs or Tier S2 for specialty drugs.

Exception requests are not available for drugs excluded by the plan, lower copayments, or tier exceptions.

The formulary exception process applies to the prescription drug benefit only. It does not apply to professionally administered drugs.

For more information about the prescription drug formulary exception process, contact Navitus at 833-354-2226 or www.navitus.com.

We have made every effort to accurately describe the benefits and ensure that information given to you is consistent with other benefit-related communications. However, if there is any discrepancy or conflict between information in this document and other plan materials, the terms outlined in the plan document will govern.

Benefit summary

Prescription drug benefits are categorized as retail, retail 90 (90-day prescription), mail order, and specialty pharmacy.

Preventive (All plans)

In-network pharmacy: The plan pays 100%.

Preventive prescription drugs as described in the Preventive care services benefit are covered.