| Choice Plus Prescription Drugs Coverage Information | ||
|---|---|---|
| In Network | Out Of Network | |
| Retail (30 day supply) | ||
| Generic | $10 | No Coverage |
| Brand | $30 | No Coverage |
| Non-Formulary | $50 | No Coverage |
| Specialty | $200 | No Coverage |
| Retail Maintenance (90 day supply) | ||
| Generic | $30 | No Coverage |
| Brand | $90 | No Coverage |
| Non-Formulary | $150 | No Coverage |
| Specialty | Available 30 days retail only | No Coverage |
| Mail Order (90 day supply) | ||
| Generic | $30 | No Coverage |
| Brand | $90 | No Coverage |
| Non-Formulary | $150 | No Coverage |
| Specialty | Available only 30 days retail | No Coverage |
| HDHP Prescription Drugs Coverage Information | ||
|---|---|---|
| In Network | Out Of Network | |
| Retail (30 day supply) | ||
| Generic | $10 After Deductible | No Coverage |
| Brand | $30 After Deductible | No Coverage |
| Non-Formulary | $50 After Deductible | No Coverage |
| Specialty | $200 After Deductible | No Coverage |
| Retail Maintenance (90 day supply) | ||
| Generic | $30 After Deductible | No Coverage |
| Brand | $90 After Deductible | No Coverage |
| Non-Formulary | $150 After Deductible | No Coverage |
| Specialty | Available 30 days retail only | No Coverage |
| Mail Order (90 day supply) | ||
| Generic | $30 After Deductible | No Coverage |
| Brand | $90 After Deductible | No Coverage |
| Non-Formulary | $150 After Deductible | No Coverage |
| Specialty | Available only 30 days retail | No Coverage |
Tools to help you make the most of your pharmacy benefits are at your fingertips, 24 hours a day,
7 days a week. Log in to Navitus’ secure member portal at www.navitus.com or visit your plan’s website for access to:
UnitedHealthcare
Navitus
