A Member’s Guide to Pharmacy Benefits

Picking up a prescription sounds like a straightforward process: your provider prescribes it, your pharmacy dispenses it and you’re on your way. Most people don’t even think about their pharmacy benefit until they’re standing at the counter, ready to pick up a medication, only to hear a price that doesn’t match their expectations. And when you’re already trying to take care of your health, that kind of surprise is the last thing you need.

The good news is that you actually have more control than it feels like in that moment. Your pharmacy benefit isn’t just “what your plan pays.” It also comes with tools and options that can help you lower costs, avoid delays and make refills easier. And one of the best ways to save on drugs is to understand how your benefit actually works.

In this blog, we’ll explain key terms, show how your pharmacy benefit fits into your overall plan and share practical ways to save, so next time you fill a prescription, you’re not guessing the price. You’re choosing the best one. 

Who Is Really Involved In Your Pharmacy Benefit?

Your pharmacy benefit is the part of your plan sponsor’s offerings (employer or health plan) that manages prescription medications. To try and get you the best prices, your plan sponsor partners with a pharmacy benefit manager (PBM) to run day-to-day mechanics. A PBM helps manage what prescriptions your plan covers, which pharmacies are in your network and how much you pay for certain drugs. This partnership gives you access to safe, effective therapies and controls costs through tools like formularies, clinical reviews and negotiated pricing. 

Here’s how it plays out:

You visit the doctor. They prescribe a medication based on what you need.

You choose the best option for you. You can decide where to fill prescriptions and use digital tools to compare prices, review alternatives and manage refills.

Your pharmacy fills the prescription. They check your coverage and price at the counter.

Your pharmacy benefit kicks in. Your PBM works behind the scenes to determine coverage, pricing and options that can lower your out-of-pocket costs. 

Knowing those behind-the-scenes nuances matters, because the price you see at the counter is not a random occurrence. It’s the result of those benefit rules being applied in real time. And once you understand who’s involved and how the benefit runs, that counter price moment stops being confusing and becomes predictable.  

Some Key Terms You Need to Know

Now that you’ve got the big picture of how the process works, it’s time to learn a few basics so you can review your benefit plan materials with confidence. That’s why we’ve put together a list of the most commonly used terms. 

Drug Formulary or Preferred Drug List: The list of medications your plan covers under the pharmacy benefit. Formularies are often organized into “tiers” that affect what you pay. 

Copayment: A fixed dollar amount you pay for a prescription. Copays may vary by tier or drug type. For example, $10 brand/$6 generic copayments.   

Deductible: The amount you pay out of pocket before your prescription coverage kicks in. Until you meet it, you may be required to pay the full cost of your prescriptions. After that, you may only pay a copay or a coinsurance when filling a prescription.  

Pharmacy Network: A group of pharmacies with which a PBM contracts to provide pharmacy services to its members. Using an in-network pharmacy usually means lower negotiated prices and better coverage terms. 

Prior Authorization: A review process required for certain medications before the plan covers them. Typically, your prescriber has to submit additional information to confirm the drug is appropriate. Learn more about prior authorization.

Don’t see a term covered here? Visit the full benefit glossary.  

Common Misconceptions About Pharmacy Benefits

Even after you understand the process and the key terms, misconceptions can still sneak in as “helpful” advice from someone who’s confidently wrong. And those half-truths are expensive. The best way to keep common misconceptions from steering your decisions is to educate yourself. That way, you can ask better questions, avoid costly mistakes and make more informed choices. 

Here are a few of the big ones worth clearing up: 
 
PBMs Set the Final Price I Pay: PBMs administer benefits and apply your plan’s coverage rules, but they don’t set retail prices. What you pay at the counter is driven by formulary placement, plan design (copay/coinsurance/deductible) and negotiated rates.  

I Can’t Choose My Pharmacy: You often have options within your plan’s network, including retail, mail order and specialty pharmacies. Check your portal or app to see in-network choices and compare prices.  

Prior Authorization is a Barrier: Prior authorization is meant to ensure therapy is appropriate, safe and cost-effective, especially for complex or high-cost medications. If a drug requires prior authorization, your prescriber typically needs to submit a bit more information before the prescription can be filled.  

Three Ways to Save on Prescriptions Using Your Pharmacy Benefit

One in five adults say they haven’t filled a prescription because of the price.¹ And that’s exactly why understanding your benefit matters, because saving money shouldn’t mean sacrificing your health. Your benefit is designed with evidence-based options that help keep care accessible and affordable.  

Here are a few smart ways to lower your prescription costs: 

1. Consider a generic: Did you know that brand-name drugs can be 20x more expensive than their generic equivalent? Generics use the same active ingredients and go through the same rigorous U.S. Food and Drug Administration (FDA) testing. If you’re taking a brand drug, ask your provider if a generic is appropriate. 
2. Take advantage of convenient 90-day refills: Ask your prescriber if you can get a 90-day supply of your regular medicine(s) instead of a 30-day supply. Not only does this mean fewer trips to the pharmacy, but it can also reduce what you pay out of pocket, especially if your plan offers better pricing for extended supplies. To learn more, check your plan details on the Navitus member portal or your plan’s website. 
3. Explore your pharmacy benefit tools: The Navitus member portal and mobile app are easy ways to make the most of your pharmacy benefits. Once you are registered, you can compare drug prices at your local and mail-order pharmacies, check coverage details and view your member ID card. 

Not Sure What To Do Next?

Pharmacy benefits can be confusing. If you’re unsure about a medication, facing a costly surprise or dealing with a prior authorization, use the number on the back of your member ID card to reach out to our customer care team for 24/7 support.

References

1. Sparks, G., Lopes, L., Montero, A., Presiado, M., & Hamel, L. Americans’ challenges with health care costs. KFF. Published January 29, 2026. Accessed February 2, 2026. https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/