Prescription Drugs

Your prescription drug benefit includes coverage for medications on the Part D formulary, plus additional drugs not covered by Medicare Part D, called Over-the-counter drugs. Learn more about the formulary.

Log in to the Navitus member portal for a personalized view of your coverage and to preview drug costs, search for pharmacies, see your benefits, and view the Navitus MedicareRx Medicare Part D formulary. (Prospective members can use these features on the unsecured Navitus portal.)

Retail network pharmacies: Fill up to a 90-day supply through the Navitus national network of retail pharmacies. Sign in to the Navitus member portal to view the complete list of network pharmacies and find a pharmacy near you.

• Tier 1 (preferred generic): $10 (30-day supply)/$30 (90-day supply)
• Tier 2 (preferred brand): $30 (30-day supply)/$90 (90-day supply)
• Tier 3 (non-preferred): $45 (30-day supply)/$135 (90-day supply)
• Tier 4 (specialty): $30 (maximum 30-day supply)

UC pharmacies and select retail pharmacies: Fill up to a 90-day supply at CVS, Walgreens, Costco, Safeway/Vons and Walmart or UC pharmacies [PDF].

• Tier 1 (preferred generic): $20
• Tier 2 (preferred brand): $60
• Tier 3 (non-preferred): $90
• Tier 4 (specialty): $30 (maximum 30-day supply)

Mail order: Fill up to a 90-day supply of maintenance medications (those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure and high cholesterol) through the Costco Mail Order Pharmacy. 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].

• Tier 1 (preferred generic): $20
• Tier 2 (preferred brand): $60
• Tier 3 (non-preferred): $90
• Tier 4 (specialty): Not available

Dispense as written (DAW) penalty: If you or your doctor writes a prescription for a brand-name drug for which there is generic equivalent on the Medicare Part D formulary, you will pay the applicable brand-name (tier 2 or 3) copay plus the difference in cost between the brand-name and the generic equivalent. Your total cost will not exceed the full cost of the brand-name medication. Exceptions for medical necessity can be made with prior authorization from Navitus.

Select generic drugs: No-cost generic drugs used to treat certain chronic conditions, including diabetes, hypertension and high cholesterol — with zero out-of-pocket expense to you at any in-network retail pharmacy or the Costco Mail Order Pharmacy. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.  

Over-the-counter drugs: Coverage for medications that are often excluded from Part D coverage, including prescription medications for cough and cold, vitamins and minerals, and lifestyle drugs, including those used to treat erectile dysfunction (ED). Over-the-counter drugs do not count toward your true out-of-pocket expenses. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.

Specialty medications: Lumicera Health Services is the preferred pharmacy for specialty medications — higher-cost prescription drugs used to treat complex conditions and that generally require special handling and storage. Just visit Lumicera online or call (855) 847-3553 to get started. Lumicera offers free delivery to your home or other locations. Specialty medications administered in your doctor’s office (e.g., Botox) may be covered under your medical benefit (through CVS Specialty pharmacy). Call Anthem Health Guide toll-free at (844) 437-0486 for information about actions you or your doctor needs to take. Certain UC pharmacies [PDF] also dispense specialty medications. You can also work with your provider to order specialty medications through these pharmacies.

Prescription drug out-of-pocket maximum: Medicare has a $7,400 out-of-pocket maximum for Medicare Part D prescription drugs (known as the “true out-of-pocket maximum,” or TrOOP), which is the most you will pay for covered Medicare Part D prescriptions in a calendar year. The TrOOP is separate from (and does not count toward) the medical out-of-pocket maximum and does not include over-the-counter drugs. After you meet the TrOOP, you get 100% coverage for Medicare Part D covered prescription drugs for the remainder of the year.

Coverage restrictions: Some covered drugs may have additional requirements or limits on coverage. For more details, see the Navitus MedicareRx formulary [PDF].

• Prior authorization: Generally, your doctor must show that a particular drug is medically necessary. You and your physician will need to get approval from Navitus MedicareRx before the prescription can be filled. Log in to the Navitus member portal to learn more about prior authorization.
• Quantity limits: For certain drugs, Navitus MedicareRx limits the amount of the drug that it will cover. For example, Imitrex (used to treat migraines) is limited to 18 tablets per prescription.
• Step therapy: In some cases, Navitus MedicareRx requires you to first try certain drugs to treat your medical condition before it will cover another drug for that condition.
• Prescriptions filled outside the U.S.: Medicare doesn’t cover outpatient prescription drugs filled by pharmacies outside the U.S. However, they are covered in full (after any applicable copay) through your Navitus MedicareRx plan (specific rules apply). Learn more about prescription coverage outside the U.S.

Your prescription drug benefit includes coverage for medications on the Part D formulary, plus additional drugs not covered by Medicare Part D, called Over-the-counter drugs. Learn more about the formulary.

Log in to the Navitus member portal for a personalized view of your coverage and to preview drug costs, search for pharmacies, see your benefits, and view the Navitus MedicareRx Medicare Part D formulary. (Prospective members can use these features on the unsecured Navitus portal.)

Retail network pharmacies: Fill up to a 90-day supply through the Navitus national network of retail pharmacies. Sign in to the Navitus member portal to view the complete list of network pharmacies and find a pharmacy near you.

• Tier 1 (preferred generic): $10 (30-day supply)/$30 (90-day supply)
• Tier 2 (preferred brand): $30 (30-day supply)/$90 (90-day supply)
• Tier 3 (non-preferred): $45 (30-day supply)/$135 (90-day supply)
• Tier 4 (specialty): $30 (maximum 30-day supply)

UC pharmacies and select retail pharmacies: Fill up to a 90-day supply at CVS, Walgreens, Costco, Safeway/Vons and Walmart or UC pharmacies [PDF].

• Tier 1 (preferred generic): $20
• Tier 2 (preferred brand): $60
• Tier 3 (non-preferred): $90
• Tier 4 (specialty): $30 (maximum 30-day supply)

Mail order: Fill up to a 90-day supply of maintenance medications (those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure and high cholesterol) through the Costco Mail Order Pharmacy. 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].

• Tier 1 (preferred generic): $20
• Tier 2 (preferred brand): $60
• Tier 3 (non-preferred): $90
• Tier 4 (specialty): Not available

Dispense as written (DAW) penalty: If you or your doctor writes a prescription for a brand-name drug for which there is generic equivalent on the Medicare Part D formulary, you will pay the applicable brand-name (tier 2 or 3) copay plus the difference in cost between the brand-name and the generic equivalent. Your total cost will not exceed the full cost of the brand-name medication. Exceptions for medical necessity can be made with prior authorization from Navitus.

Select generic drugs: No-cost generic drugs used to treat certain chronic conditions, including diabetes, hypertension and high cholesterol — with zero out-of-pocket expense to you at any in-network retail pharmacy or the Costco Mail Order Pharmacy. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.  

Over-the-counter drugs: Coverage for medications that are often excluded from Part D coverage, including prescription medications for cough and cold, vitamins and minerals, and lifestyle drugs, including those used to treat erectile dysfunction (ED). over-the-counter drugs do not count toward your true out-of-pocket expenses. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.

Specialty medications: Lumicera Health Services is the preferred pharmacy for specialty medications — higher-cost prescription drugs used to treat complex conditions and that generally require special handling and storage. Just visit Lumicera online or call (855) 847-3553 to get started. Lumicera offers free delivery to your home or other locations. Specialty medications administered in your doctor’s office (e.g., Botox) may be covered under your medical benefit (through CVS Specialty pharmacy). Call Anthem Health Guide toll-free at (844) 437-0486 for information about actions you or your doctor needs to take. Certain UC pharmacies [PDF] also dispense specialty medications. You can also work with your provider to order specialty medications through these pharmacies.

Prescription drug out-of-pocket maximum: This plan has a $1,000 out-of-pocket maximum for Medicare Part D prescription drugs that is separate from (and does not count toward) the medical out-of-pocket maximum. Out-of-pocket costs for over-the-counter drugs apply toward the out-of-pocket maximum, but not the $7,400 TrOOP. Members qualifying for the Coverage Gap Discount could reach TrOOP before the $1,000 out-of-pocket maximum because out-of-pocket expenses covered by the Coverage Gap Discount apply only toward the TrOOP, but not the out-of-pocket maximum. If this happens, members will continue to pay a copayment for over-the-counter drugs until reaching the $1,000 out-of-pocket maximum. After that, the plan will pay 100% for all covered drugs (including over-the-counter drugs) for the remainder of the calendar year.

Coverage restrictions: Some covered drugs may have additional requirements or limits on coverage. For more details, see the Navitus MedicareRx formulary [PDF].

• Prior authorization: Generally, your doctor must show that a particular drug is medically necessary. You and your physician will need to get approval from Navitus MedicareRx before the prescription can be filled. Log in to the Navitus member portal to learn more about prior authorization.
• Quantity limits: For certain drugs, Navitus MedicareRx limits the amount of the drug that it will cover. For example, Imitrex (used to treat migraines) is limited to 18 tablets per prescription.
• Step therapy: In some cases, Navitus MedicareRx requires you to first try certain drugs to treat your medical condition before it will cover another drug for that condition.
• Prescriptions filled outside the U.S.: Medicare doesn’t cover outpatient prescription drugs filled by pharmacies outside the U.S. However, they are covered in full (after any applicable copay) through your Navitus MedicareRx plan (specific rules apply). Learn more about prescription coverage outside the U.S.

Medicare Part B is Your Primary Insurance for Diabetic Supplies

Like other Medicare-covered services, Medicare pays first (through Part B), then your UC PPO plan benefits generally pay the rest of the cost.*

1. Confirm Your Pharmacy Will Bill Medicare Part B

While most large retail pharmacies can bill Medicare Part B, there are some exceptions. 

Before filling a prescription:

• Call the pharmacy and ask “Are you enrolled in Medicare?,” “Do you accept Medicare assignment,” and “Can you bill Medicare Part B for diabetic supplies?” If not, choose a different network pharmacy.
• Confirm your chosen pharmacy is in the Navitus MedicareRx network. Log on to the Navitus member portal or call Navitus MedicareRx Customer Care at (833) 837-4309, available 24 hours a day, 7 days a week, except Thanksgiving and Christmas Day. 

2. Submit Your Prescription

If you are ordering supplies within Medicare standard limits (see If You Need Large Quantities), either you or your doctor can send the prescription for your diabetic supplies to the pharmacy.

If you are dropping off the prescription, ask the pharmacy to first bill Medicare Part B and then submit a claim to Navitus MedicareRx for secondary payment.

If You Need Large Quantities

Requests within Medicare's monthly allowed limits (300 strips and lancets every 3 months for insulin users, 100 for non-insulin users) can be filled with just a doctor's prescription.

If you need a larger quantity, ask your doctor to call Noridian’s Medicare “Medical Provider Line” at (855) 609-9960. Your doctor will need to submit documentation that includes: 

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

This documentation is typically needed only for the initial prescription fill. 

Once approved by Medicare, your doctor will need to send the prescription and documentation to the pharmacy. Your pharmacy will need to forward both your doctor’s statement and prescription to Medicare.

*Your UC pharmacy benefit plan pays through the Navitus WRAP/Extra Covered Drug (ECD) benefit, not the Part D benefit. 

When you fill prescriptions at Navitus network pharmacies, there are no claim forms to fill out. Your pharmacy handles all the paperwork. If you use an out-of-network pharmacy, it's up to you to submit a claim for reimbursement for services received or prescriptions. The easiest way to file an out-of-network claim is through the Navitus member portal.

A formulary is an extensive list of safe, effective medications covered by a health plan. Every pharmacy benefit manager (Navitus MedicareRx, 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. Generally, if drugs aren’t on the formulary, they aren’t covered by the plan.

The Navitus MedicareRx Medicare Part D formulary [PDF] is divided into four tiers (alphabetical list starting on page 115). 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 amlodipine to treat it. The formulary shows amlodipine is in Tier 1, so you know what you’ll pay.

The formulary also will show if any restrictions and rules apply, such as quantity limits.

View Your Costs

Log in to the Navitus member portal for a personalized view of your coverage and to preview drug costs, search for pharmacies, see your benefits, and view the Navitus MedicareRx Medicare Part D formulary. (Prospective members can use these features on the unsecured Navitus portal.)

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. These medications include drugs such as atenelol and are indicated as $0 on the Navitus MedicareRx Medicare Part D formulary [PDF] (alphabetical list starting on page 115). Search by name on the Navitus drug cost and pharmacy search tool. (Choose your plan, then search.)

Before filling a prescription, find out if the drug is covered. A quick search of the Navitus MedicareRx Medicare Part D formulary [PDF] will tell you. 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 MedicareRx Customer Care at (833) 837-4309 for help.

Each month, the Centers for Medicare and Medicaid Services (CMS) changes the Medicare Part D prescription drug formulary. Updates are shown below. See the Navitus MedicareRx Medicare Part D formulary [PDF] (alphabetical list starting on page 115) for more details about your Medicare and Navitus prescription drug coverage.

March 2023

February 2023

November 2022

October 2022

September 2022