Goshen Community Schools Plan C

YOUR PHARMACY BENEFITS

Welcome to Navitus We understand that access to affordable medications can be life changing - and lifesaving. Our mission is to help members like you get the medications you need. Once your pharmacy benefits are active, here’s how you can make the most of them: Provide your prescription card when you fill a medication. This will ensure that your pharmacy benefits are processed seamlessly. Use our member portal to access your benefits. Find the nearest network pharmacies, cost of your medications, access your digital ID card, review plan details such as deductibles and out-of-pocket maximums and more. To get started, go to memberportal.navitus.com. Still have questions? As a Navitus member, you have peace of mind knowing that we are here to support your health journey. Our dedicated Customer Care team can help if you have questions about your pharmacy benefits. They will work to resolve any concerns quickly and can be reached at the number on the back page. Saving Money on Your Prescriptions One of the best ways to lower your prescription expenses is by choosing generic drugs. Generics are clinically identical and just as safe as their brand-name counterparts. They go through the same rigorous U.S. Food and Drug Administration (FDA) process as brand name drugs. To get started simply ask your prescriber if a generic is available for your prescription.

Your Pharmacy Benefits Eff ective Date January 1, 2020 Benefi t 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 Benefi t Structure - Plan C (HDHP) Kroger Retail Retail Pharmacy Applies to Tier Pharmacy Mail Order Up to 34-Days Out-of-Pocket Level 35-90 Days 90-Day Supply Supply Maximum Supply* Tier 1 $10 10% 10% Yes Greater of Greater of Greater of Tier 2 Yes $40 or 40% $40 or 40% $40 or 40% Greater of Greater of Greater of Tier 3 Yes $60 or 60% $60 or 60% $60 or 60% *Fills for Days’ Supply greater than 34 are limited to Kroger pharmacies Specialty - Plan C (HDHP) Lumicera Pharmacy 10% Annual Deductible - Plan C (HDHP) - copays will not apply until the deductible is satisfi ed Combined Individual Deductible $3,200 Medical and Rx Combined Family Maximum $6,400 Medical and Rx Annual Out-of-Pocket Maximum - Plan C (HDHP) - copays will no longer apply once the out-of-pocket maximum is satisfi ed Combined Individual Maximum $5,950 Medical and Rx Combined Family Maximum $11,900 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

Experience Convenient Access to Your Pharmacy Benefits Register on the Navitus member portal for tools to help you make the most of your pharmacy benefits. Go to memberportal.navitus.com or scan the QR code to sign up today.* * The QR code may identify your IP/device information. However, your personal and health information is strictly confidential and will not be captured. Contact Information Customer Care Member Portal 24 hours a day, 7 days a week memberportal.navitus.com 844-268-9789 711 (TTY) Mail Order Prescription Claims Postal Prescription Services Navitus Health Solutions 800-552-6694 Attn: Claims Department ppsrx.com PO Box 999 Specialty Pharmacy Appleton, WI 54912-0999 Lumicera Health Services Fax: 855-668-8550 (toll-free) 855-847-3553 Navitus Website lumicera.com navitus.com/members Sharing Your Feedback Your experience with your Navitus pharmacy benefits matters to us. Go to bit.ly/navitusfeedback or scan the QR code* to tell us how we are doing. * The QR code may identify your IP/device information. However, your personal and health information is strictly confidential and will not be captured. 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. © 2023 Navitus Health Solutions, LLC. All rights reserved.