Prescription medications
Navitus Pharmacy Benefits
OhioHealthy provides prescription coverage through Navitus Health Solutions. As an OhioHealthy member, know that we are here to support your health and well-being with access to the drugs you need at the lowest cost.
Navitus offers:
- A high-performance formulary that offers lower-cost alternatives like generics or less expensive brand name drugs when clinically appropriate.
- A large pharmacy network including OhioHealth Pharmacies.
- An Access Guidance Program to help you make the most of your specialty pharmacy benefits.
Log in to view the formulary or find a medication
Go to NavitusHow do I make the most of my pharmacy benefit?
Visit a Network Pharmacy
Show your OhioHealthy member ID card when you visit a retail network pharmacy. This helps to make sure your claims are processed quickly and accurately. You can find a list of network pharmacies at memberportal.navitus.com.
Try Mail Order
Save time and money by using Costco Pharmacy to have your prescriptions mailed directly to you. To get started, simply register at pharmacy.costco.com or call (800) 607-6861.
Specialty Pharmacy
Navitus utilizes Lumicera Specialty Pharmacy and OhioHealth Specialty Pharmacy to serve the unique needs of members with complex conditions such as rheumatoid arthritis, multiple sclerosis, cancer and hepatitis C. To receive these drugs through your pharmacy benefit, you will need to fill them through one of these pharmacies. To fill through one of these pharmacies call Lumicera Specialty Pharmacy at (855) 847-3553 or OhioHealth Specialty Pharmacy at (614) 566-3322.
Access Guidance
Navitus provides clinical and financial guidance to help you make the most of your specialty pharmacy benefits. Call the Access Team at (855) 847-3556. They can help you find and enroll in assistance programs that may reduce your out-of-pocket costs. Participation in this program is required when available. Only the amount you pay out-of-pocket will apply to your annual deductible and/or maximum out-of-pocket.
Phone Numbers
- Navitus Customer Care: (855) 673-6504
- Costco Mail Order Pharmacy: (800) 607-6861
- Lumicera Specialty Pharmacy: (855) 847-3553
- Access Guidance (aka Copay Assist Program): (855) 847-3556
- OhioHealth Specialty Pharmacy: (614) 566-3322
How much does this benefit cost?
Prescription coverage is included in your medical plan premiums. The way you pay for prescription medications depends on the medical plan option you choose:
- OhioHealthy HDHP: You pay the full cost of covered medications until you meet your deductible. Then, the plan pays 90% of the cost of most covered medications, and you pay 10%. You may use your HSA funds to pay for medications.
- OhioHealthy PPO: There is a separate per person prescription drug deductible to meet for Tier 1 medications. It’s $100 for Associate Only coverage, $200 for Associate + 1, and a maximum of $300 for Associate + 2 or more. Each member pays the full cost of covered medications in Tier 1 until their deductible is met. Then you will pay a flat copay for covered medications in Tier 1 after you meet the deductible. For all other tiers, there is no separate deductible to meet and you will pay only coinsurance for covered medications.
- OhioHealthy PPO Assist: There are flat copays or coinsurance for different tiers of medication; there is no deductible to meet.
Good to know
| Term | Definition |
|---|---|
| Formulary/Prescription Drug List (PDL) | A list of medications covered by your medical plan, organized into tiers – the higher the tier, the higher the cost of the medication. This list can be updated monthly. If you are prescribed a medication, check to see if it appears on this list; if not, discuss the possible alternatives with your healthcare provider to save money. To view the most recent version of the formulary, log in to your member portal at memberportal.navitus.com |
| Mandatory generic | If you choose a brand name medication when a generic is available, you will pay the coinsurance, plus the cost difference between the two drugs (the difference does not count toward your deductible or out-of-pocket maximum). |
| Specialty medication | A medication that requires special handling, administration or monitoring — typically one used to treat complex conditions. Prescriptions for these must be filled through OhioHealth Specialty Pharmacy or Lumicera. Call Lumicera Specialty Pharmacy at (855) 847-3553 or OhioHealth Specialty Pharmacy at (614) 566-3322. |
| Step therapy | For some medical conditions, there are drugs with similar clinical effectiveness but wide variation in price. You may need to try a ‘step 1’ medication before a ‘step 2’ medication is covered. |
| Prior authorization | Some medications require prior authorization before a prescription can be filled. Your doctor or your pharmacist will let you know if you need prior authorization. |
| Quantity limits | Some medications have quantity limits to promote the appropriate use of medications, prevent waste and help control costs. |
| Maintenance medications/90-day supplies | Some medications that are taken regularly or for an ongoing condition are called maintenance medications. You have the option of filling a three-month supply of your maintenance medication at any in-network retail pharmacy including OhioHealth Pharmacies. 90 Day Supply does not apply to specialty medications. |
| Using coupons |
Drug manufacturers often issue coupons to encourage continued use of a more expensive brand name drug, even though less expensive similar or equivalent options have become available. Note that if dollars covered by a manufacturer coupon are applied toward your deductible you may have tax reporting implications. Navitus will provide guidance to connect patients to the clinical and financial solutions they need to make the most of their pharmacy benefit. This copay savings program is required when available on specialty pharmacy medications and may be expanded to retail medications in the near future. If you fill a prescription for a specialty drug and use a manufacturer copay assistance program to reduce your out-of-pocket cost for the drug, only the actual amount you pay will count toward your deductible and out-of-pocket maximum. Participation is required when available. |
| Diabetes and Asthma | If you’re enrolled in our medical plan and are actively participating in the OhioHealth disease management program for Diabetes or Asthma, you may qualify to have certain medications paid for at 100%. (If you are enrolled in the OhioHealthy HDHP+HSA, you will need to meet your deductible first.) |
More tips to make the most of this benefit
- Ask your healthcare provider for generic medication or one listed on our Formulary/Prescription Drug List that might work for you.
- Download the Navitus App so you can discuss medication options with your healthcare provider on-the-go during your consultation.
- Use the Navitus Member Portal or app to research the cost of a medication at different pharmacies (you must use OhioHealth Specialty Pharmacy or Lumicera for specialty medications), see lower-cost alternatives and explore pricing for different dosage options (for example, occasionally two 50mg capsules can cost less than one 100mg tablet).
- Follow all instructions and take your medications according to the prescribed schedule
- Call your physician or pharmacy if you have questions or any concerns about drug interactions.
- Combine this benefit with a Health Savings Account (HSA) or Healthcare Flexible Spending Account (Healthcare FSA) to get eligible out-of-pocket expenses reimbursed.
- If you have an HSA or Healthcare FSA, use your debit card to pay for your prescription medicines and save your receipts on the HealthEquity mobile app.