The State Group Health (SGH) Pharmacy Benefits are included in the State Group Health insurance plan designs. This means if you have any of the State Group Health insurance plans, your pharmacy benefits are a part of the total health benefit for the price of your health insurance.

Resources:

• 2025 Health & Pharmacy Benefits Plan Design Comparison, page 5
• Navitus Formulary, updated as of 10/1/24
• Certificate of Coverage for Pharmacy Benefits

Changes: There are no changes for the benefit year of 2025.

SGH Pharmacy Benefits – Navitus

Navitus Health Solutions are the administrators for the SGH Pharmacy Benefits. All plan designs require the use of an in-network pharmacy. You can confirm your pharmacy is in-network at www.Navitus.com or by calling Navitus at 866-333-2757.  

Services received from non-participating pharmacies are not covered except for Emergency or Urgent situations.

Separate ID cards are issued to employees by the individual health insurance carrier and Navitus. You can register and login to print a pharmacy benefits ID card online at www.navitus.com.

The 2025 Health & Pharmacy Benefits Plan Design Comparison, on page 5, provides the benefits associated with each of our health plan designs. All covered prescriptions are categorized into one of the cost-shaving Levels or 1, 2, 3, and 4 or are considered a Preventative medication under the Affordable Care Act (ACA).

• Level 1
  • $5 copay
  • Includes preferred Generic prescriptions (least expensive) and certain lower-cost preferred Brand Name medication
• Level 2 
  • 20% co-insurance ($50 max)
  • Preferred Brand Name medications and certain higher cost preferred Generic medications
• Level 3 
  • 40% co-insurance ($150 max)
  • Non-preferred Brand Name prescriptions and certain high-cost Generic medication which alternative/equivalent preferred Generic and Brand Name medications are covered 
  • Dispense as Written medications are 40% coinsurance plus the cost difference between the brand and Generic medications applied unless the member has a medical need, and their doctor has submitted a one-time FDA MedWatch form
• Level 4
  • $50 copayment
    • Includes specialty medications filled at a Preferred Specialty Pharmacy
      • Lumicera Health Services
      • UW Specialty Pharmacies
    • Mandatory for non-Medicare Participants
  • 10% coinsurance ($200 max)
    • Only applies to those with Medicare
    • Specialty medications are filled at a pharmacy other than a Preferred Specialty Pharmacy

• Preventative Health Benefits & Coverage
  • www.Healthcare.gov
  • are used for breast cancer prevention, cardiovascular disease primary prevention, colorectal cancer screening, heart attack prevention, human immunodeficiency virus (HIV) pre-exposure prophylaxis, smoking cessation, and vitamins and minerals for children and women planning or capable of pregnancy

Navitus also has a handy tool: Drug Cost Preview.  It provides the Tier of the medication, in some cases the actual cost, and a list of in-network pharmacies from your search parameters.   

• Pharmacy Search – https://benefitplans.navitus.com/etf/home
• Choose your health plan
  • IYC Health Plan-IYC Access Plan State-Local Plan
  • ETF – IYC HDHP Plan-IYC Access HDHP Plan State-Local Plan
• Click on Drug Cost Preview
• Click on Future 2025 Plan Year
• Enter your medication name
• Enter your Zip Code and radius for pick up

Prior Authorization

Some medications require prior authorization.  A prior authorization is initiated by the prescribing physician on your behalf.  Navitus will review the prior authorization request within 48  hours of receiving all necessary information from the physician.  Mediations that require prior authorization are marked with “PA” on the Navitus Formulary List.

What If…

Saving You Money

Did you know that your UW Pharmacy Benefits offer several programs that could potentially save you money?

• RxCents Tablet-Splitting
  • Save up to 50% on out-of-pocket costs on select medications!
    • Members will pay half the normal copayment amount
  • Voluntary program where a member can split the tablet of a higher strength dosage at home
  • Member will half the usual quantity for a 30-day supply
  • Medications eligible for tablet splitting are designated on the Navitus Formulary List
• Over-The-Counter
  • Some certain over-the-counter medications may be covered instead of paying full price!
  • Over-the-counter medication are shown with the Special Code of OTC on the Navitus Formulary List
• 90-Day at Retail Program
  • Save 2 trips to the pharmacy!
  • Maintenance medications are prescriptions taken on a regular, recurring basis.
  • To use the program, a member must have 3 consecutive, 30-day supply claims processed and then the doctor can write the prescription for 90-day
  • Must still pay 3 copays for 90-day supply
• Serve You RX Mail Order Program – full-service pharmacy benefit manager
  • Save time and one copay with prescriptions delivered to your door!
  • Receive free standard shipping
  • Ability to set up automatic refills
  • https://serveyourx.com/members/navitus-members/
• Discount Eligible Medications
  • Pay 100% of the discounted rate!
  • Amounts will not count towards any OOPL. 
  • Some medications used to treat weight loss, infertility, and hair loss that are not covered by a member’s pharmacy benefit, but a member can still buy them at a discount
  • To see the complete Discount Drug List visit https://etf.benefits.navitus.com/ and click on the name of the plan’s Formulary (Navitus).
    • Then click on the word Formulary on the left side of the screen. The option to view the ETF Discount Drug List will appear on the list in the middle of your screen.
• Specialty Medications
  • Delivered right to your door!
  • Include medications that treat complex, chronic, or rare conditions including investigational medications 
  • Usually the most expensive medications on the pharmaceutical market 
  • Must be filled at a Preferred Specialty Pharmacy
    • Lumicera Health Services
    • UW Specialty Pharmacies

Additional Ways to Save. These options are not endorsed or recommended by UW. They are only shown as additional options to decrease the cost of medications.

• Copay Assistance
  • Some pharmaceutical companies offer copay assistance to reduce the cost of employee copayments in the form of a rebate.
  • Reach out to your medication pharmaceutical company online or by phone to learn if they offer copay assistance programs.
  • Check with your doctor, nurse, or pharmacy where your prescription is filled.  
    • Example: Humira
      • Cost per month – $6,922
      • Tier 4 – must purchase thru the Specialty Pharmacy
      • AbbVie, maker of Humira, offers a HUMIRA Complete Savings card
      • Offsets the $50 copayment to $0 in some cases
    • Example: FreeStyle Libre 3, 2 sensors per month
      • If you pay over $75 for 2 sensor per month you can get an Abbott eSavings voucher to start saving immediately on your sensors
• Walmart Rx Program-Generic Retail Rx List
  • $4 for 30-day supply or $10 for 90-day supply of select generic medications in commonly prescribed dosages
  • $9 for 30-day supply or $24 for 90-day supply of certain Family Planning and Men’s health and other generic drugs at commonly prescribed dosages
  • $15 for 30-day supply or $38 for 90-day supply of additional select generic medications in commonly prescribed dosages

Discount Savings Card(s) – to name a few

• Good RX
  • Compare UW insurance cost to GoodRx cost to determine best savings for you
  • Searches for medications, compares prices, finds coupons and/or discounts
  • Example: FreeStyle Libre 3
    • Lowest price at HyVee at $140.18 and highest price at Walgreens at $153.76.
    • Print a voucher to present at pharmacy

• Optum Perks
  • Compare UW insurance to Optum Perks cost to determine best savings for you
  • Provides discounts on most prescriptions at over 64,000 pharmacies nationwide
  • Example: Metformin
    • Lowest price at Walmart at $4.00 and highest price at Target/CVS at $7.91
  • Discount applies to all family members

• Single Care
  • Negotiates low prices with pharmacies
  • Provides discount in a form of a coupon to take to the pharmacy
  • Example: Amoxicillin
    • Lowest price at Walmart at $3.28 and highest price at CVS at $20.86

If you have any questions or would like to set up an individual Webex or Microsoft Teams meeting, please do not hesitate to reach out to CALS HR by emailing hr@cals.wisc.edu.