Goshen Community Schools Plan B

YOUR PHARMACY BENEFITS

Welcome to Navitus We’re committed to providing you with robust, 360-degree support and personalized care because we know that when you’re healthier, you’re happier. That’s why we’ve reinvented pharmacy benefits to work smarter and give you clarity, guidance and peace of mind when it comes to prescriptions and improving your health. You can count on us to: ▶ Make it easier to understand your benefit ▶ Answer your health questions ▶ Provide convenient access to prescriptions ▶ Give you the support you need We look forward to serving you on your journey to a healthier, happier you. Filling Your Prescription At a Network Pharmacy — Getting your prescription filled is easy. You can find a complete list of your network of pharmacies on the secure member portal, as well as tools to help you select a pharmacy near you. By Mail Order — Depending on your benefit design, our mail order service may be a convenient way to get a 90-day supply of your maintenance medications. A registered pharmacist is on hand to perform the same safety checks as your local retail pharmacist, including a review of your medication history. You can rest assured that your prescription is safe, accurate and right for you. Plus, you can save a trip to the Saving Money on pharmacy by getting your medications delivered right to Your Prescriptions your door. At a Specialty Pharmacy — The specialty program gives Choosing generic drugs is one of the members with chronic conditions convenient access best ways to lower your prescription to specialty medications. This provides a high level of expenses. Generics are clinically identical to their brand-name personalized care and guidance to help successfully counterparts and go through the reduce side e昀昀ects, minimize complications and improve same rigorous U.S. Food and Drug quality of life. Administration (FDA) process as brand Filing A Claim name drugs. Rest assured they have We’re dedicated to making your pharmacy benefits easy the same safety, quality, strength and accessible. If you have a concern about a benefit, and e昀昀ectiveness as brand name medications. To get started simply ask claim or other service, please call customer care. If we can’t your prescriber if a generic is available resolve your issue, you have the right to file an appeal. To for your prescription. file a manual claim, fill out the form located in your member portal and mail or fax your claim form and documentation to us. Our customer care number and claims address are listed on the back. We’ll work to answer your questions and resolve your concerns quickly. Sharing Your Feedback We welcome you to share your feedback, concerns or complaints, or to report any errors. We consider it a top priority to act on this information and correct errors, prevent future issues and ensure quality and safe care. To provide feedback, please call the Customer Care number listed on the back cover.

Eff ective Date January 1, 2020 Benefit Type Select 3 Tier Days’ Supply Dispensed Participating Pharmacy Up to 34 Days Mail Order Up to 90 Days Specialty Pharmacy Up to 34 Days Benefit Structure - Plan B Retail Pharmacy Kroger Retail Applies to Tier Up to 34-Days Pharmacy Mail Order Out-of-Pocket Level Supply 35-90 Days 90-Day Supply Maximum Supply* Tier 1 $10 10% 10% Yes Tier 2 Greater of Greater of Greater of Yes $40 or 40% $40 or 40% $40 or 40% Tier 3 Greater of Greater of Greater of Yes $60 or 60% $60 or 60% $60 or 60% *Fills for Days’ Supply greater than 34 are limited to Kroger pharmacies Specialty - Plan B Lumicera Pharmacy 20% Annual Out-of-Pocket Maximum - Plan B - copays will no longer apply once the out-of- pocket maximum is satisfied Individual Maximum $6,000 Combined Medical and Rx Family Maximum $12,000 Combined Medical and Rx Tier 1: Usually includes generic medications Tier 2: Usually includes preferred brand-name medications Tier 3: Usually includes non-preferred brand-name medications 1410-1119MB

| | | CUSTOMER CARE: 24 Hours a Day 7 Days a Week 1.844.268.9789 711 (TTY) | | MAIL ORDER: Postal Prescription Services 1.800.552.6694 www.ppsrx.com | SPECIALTY PHARMACY: Lumicera Health Services 1.855.847.3553 CLAIMS: Navitus Health Solutions ATTN: Claims Department P.O. Box 999 Appleton, WI 54912-0999 TOLL-FREE FAX : 1.855.668.8550 WEBSITE: navitus.com/members You can get easy access to your prescription benefits through our convenient member portal at: https://members.navitus.com Hover your phone’s camera over this code to go to the portal. ▶ For a copy of your member rights and responsibilities, please visit the member portal or call Customer Care. If you need this printed material translated or in an alternative format, or need assistance using any of our services, please contact Customer Care.