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NAVITUS MEDICARERX (PDP) 2026 SUMMARY OF BENEFITS
This Summary of Benefits explains some of the features of the Navitus MedicareRx Prescription Drug Plan (PDP) for your enrollment in the Employer Group Medicare plan. However, it does not list every benefit, limitation, or exclusion. To get a complete list of your benefits, visit the member portal or contact Navitus Customer Care and reference ID: MRXPSM at 1-855-213-1106 or 920-225-7014 (local). TTY users call 711. Calls to these numbers are free. Members can call Customer Care 24 hours a day,
seven days a week, except on Thanksgiving and Christmas Day. Potential enrollees, contract your employer group for the materials. Navitus MedicareRx Member Portal: • Current members: You may access our member portal at www.Medicarerx.navitus.com, click on Members, then Login.
• New members: Once you receive your ID card, first time users can register at
www.Medicarerx.navitus.com for access to the Member Portal.
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Important Contact Information
Navitus MedicareRx Customer Care – Navitus Customer Care and reference ID: MRXPSM at 1-855-213-
1106 or 920-225-7014 (local). TTY users call 711. Calls to these numbers are free, and available 24 hours a
day, 7 days a week, except on Thanksgiving and Christmas Day. Customer Care has free language interpreter services available for non-English speakers. Pharmacies can also reach Navitus Customer Care 24 hours a day, 7 days a week. Navitus MedicareRx Member Portal - www.Medicarerx.navitus.com Existing members use this portal to access the most up-to-date formulary and pharmacy directory and to review the materials.
Potential enrollees, contact your employer group for a copy of the materials. Navitus Prescriber Portal – https//prescribers.navitus.com Your primary care physician or prescribing physician can use this portal to access your Formulary and
initiate a Prior Authorization on your behalf. Navitus Network Pharmacy Portal - https://pharmacies.navitus.com This portal allows your pharmacy to access the Formulary.
Premium or Enrollment Questions - For questions regarding premiums or enrollment options, please contact your employer group. Centers for Medicare & Medicaid Services (CMS) - CMS is the Federal agency that administers and regulates Medicare. For information on Medicare benefits only (not related to your supplemental/retiree plan), we recommend reviewing CMS’s Medicare & You booklet. This booklet is mailed out in September to all Medicare households by CMS. You can also sign up to get this handbook electronically
at MyMedicare.gov, or order a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-
877-486-2048. Calls to these numbers are free, and you can call 24 hours a day, 7 days a week.
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Navitus MedicareRx Summary of Benefits 2026
Yearly Deductible Stage:
This stage does not apply to you because this plan has no deductible for Part D drugs.
Cost Sharing Tiers
Retail Network and
Out-of-Network
1-31 days
Retail Network
32-60 days
Retail Network
61-90 days
Up to 90 days
Mail Order
Network
Up to 90 days
Tier 1: Preferred generics and certain
lower-cost brand name drugs
$5 copayment $10 copayment $15 copayment $10 copayment
Tier 2:
Preferred brand name drugs
and certain high-cost generic drugs
$20 copayment $40 copayment $60 copayment $40 copayment
Tier 3: Non-preferred drugs (may include both brand and generic)
$50
copayment
$100
copayment
$150
copayment
$100
copayment
Part D Prescription Drugs The benefit information provided summarizes what we cover and what you pay. Your cost sharing may differ based on the pharmacy’s status as preferred/non-preferred, mail order, long-term care, home infusion,
one-month or extended-day supplies, and what stage of the Medicare Part D benefit you’re in. For more
information on the additional pharmacy-specific cost-sharing, the stage of the benefit, or a complete description of benefits, please call us or existing members can access the Evidence of Coverage in the member portal.
Initial Coverage Stage:
During this stage, the plan pays its share of the cost of your drug, and you pay your share of the cost. The
table below shows your cost share in each of the plan’s drug tiers and shows your payment responsibility until
your yearly out-of-pocket drug costs reach $2,100 for Part D covered drugs.
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Catastrophic Coverage Stage: After your yearly out-of-pocket drug costs reach $2,100 for Part D covered drugs, pay $0 cost sharing for the remainder of the coverage year.
Additional Cost Sharing Information
• Your drug copay or coinsurance may be less based on the cost of the drug and the coverage stage you are in.
• Your plan will allow up to a 31-day supply of medication at an out-of-network pharmacy.
• Drugs marked as NDS (Non-extended Day Supply) on the formulary are not available for an
extended supply (greater than a one-month supply) at retail, mail-order, or specialty pharmacies.
• If you reside in a long-term care facility, you receive a 31-day supply for a 1-month copay/coinsurance.
• Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines
at no cost. Call Customer Care for more information.
• Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
For a complete description of benefits, please call Customer Care (numbers on back cover) or existing members can access the Evidence of Coverage on the member portal at www.Medicarerx.navitus.com.
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Additional Coverage Information
Your Evidence of Coverage provides more detailed plan information. You can also access these documents on the member portal at www.Medicarerx.navitus.com. You can ask for information regarding the Evidence of Coverage, Formulary and Pharmacy Directory by calling Navitus MedicareRx Customer Care; the number is
listed on the back cover.
Additional Help for Medicare called “Extra Help”
Programs are available to help people with low or limited income and resources pay for prescriptions. If you qualify, your Medicare prescription plan costs for your drug costs at the pharmacy and the amount of
your premium (there are four different premium levels, and it does not include any Part B premiums) will
be less. Once you are enrolled in Navitus MedicareRx, Medicare will tell us how much assistance you will receive and we will send you information on the amount you will pay for your prescriptions.
If you think you may qualify for Medicare’s “Extra Help” program, call Social Security 1-800-772-1213 between 8 am and 7 pm, Monday through Friday, to apply for the program. TTY users call 1-800-325-0778. You may also be able to apply at your State Medical Assistance or Medicaid Office. If you qualify
for extra help, we have included a letter in your packet called the “Evidence of Coverage Rider for People
Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider. For more information on how to get help with drug plan costs, see Chapter 2, section 7 of the Evidence of Coverage.
Coverage Determination
If your physician prescribes a drug that is not on our drug list, is not a preferred drug, or is subject to
additional utilization rules (see below), you may ask us to make a coverage exception. In addition, if Navitus MedicareRx ever denies coverage for your prescriptions, we will explain our decision. You always have the right to appeal our decision or ask us to review the claim denied.
For certain drugs, you or your prescriber need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization”. Sometimes, the requirement for getting approval in
advance helps guide the appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
A requirement to try a different drug first is called “step therapy”. Trying a different drug first encourages you to try less costly but usually just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If
Drug A does not work for you, the plan may cover Drug B.
For certain drugs, you may be limited in the amount of the drug you can have by limiting the quantity of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. A requirement that limits the quantity of a drug you can get filled is called “quantity limits”.
Creditable Drug Coverage
Creditable drug coverage is as good as Medicare’s standard prescription drug coverage. Creditable coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. A late enrollment penalty is imposed on individuals who do not maintain creditable coverage for any period of 63 days or longer after being first eligible for the Medicare Part D benefit.
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Income Related Monthly Adjustment Amount (IRMAA)
If your modified adjusted gross income (MAGI), as reported on your IRS tax return from two years ago, was above a certain amount, you will pay an extra amount in addition to your monthly plan premium. For
more information on the extra amount you may have to pay based on your income, see Chapter 1, Section 4 of the Evidence of Coverage.
Network Pharmacies
The first step to filling your prescription is deciding on a participating network pharmacy. We have network pharmacies nationwide where you can obtain your prescriptions as a member of our plan. There is a pharmacy search tool and a complete list of network pharmacies on the member portal at
www.Medicarerx.navitus.com. To access the pharmacy search tool, click on Pharmacy Search on the top navigation bar. You can ask about network pharmacies or request a pharmacy directory mailed to you by calling Navitus MedicareRx Customer Care. The number is listed on the back cover.
In the event of an emergency where you are not able to utilize a network pharmacy, an out-of-network
pharmacy may be able to fill your prescription. Your plan will allow up to a 31-day supply of medication at an out-of-network pharmacy.
Recommended Mail Order Pharmacy
Our mail-order service offers an easy way to get up to a 90-day supply of your long-term or maintenance medications. You can use any contracted network mail-order pharmacy you like; currently, the recommended one is Costco Mail Order Pharmacy. You can reach Costco Mail Order Pharmacy by calling 1-800-607-6861 or visiting their website, pharmacy.costco.com.
Using the recommended mail-order pharmacy allows you to have your medications delivered to your home, and in some cases, at a lower rate than if you purchased them at a retail pharmacy.
Note: Costco Mail Order Pharmacy use does not require a Costco Warehouse membership.
Recommended Specialty Pharmacy
You can use any contracted specialty pharmacy you like; however, Navitus recommends Lumicera
Specialty Pharmacy for providing the best home-delivery service and rates on specialty drugs. You can
contact Lumicera’s Customer Care at 1-855-847-3553 (TTY users call 711). The member portal has a pharmacy search tool and a complete list of network pharmacies at www.Medicarerx.navitus.com.
Refilling Prescriptions at a New Pharmacy
If you want to switch to a new pharmacy, automatic prescription refill transfers do not happen. Please give your Navitus ID card to your new pharmacy and let them know which pharmacy the prescription refills are located at and the medication names/strengths. Your new pharmacy can work with the previous pharmacy to see if these refills can be transferred. Some prescriptions may not be allowed to transfer, and in that case, your prescriber will need to write a new prescription.
Supplemental Coverage
Supplemental Coverage, or Wrap coverage, is provided as part of your prescription benefit. This
supplemental coverage may pay for prescription drugs even when Medicare does not cover them.
However, you will still be responsible for paying your copayments or coinsurance. The amount you pay when you fill a prescription for these drugs does not count towards the catastrophic coverage stage. In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
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General Information
What will I pay for Navitus MedicareRx premiums?
Your coverage is provided through a contract with your current or former employer. Please contact the employer group for information about your 2026 Part D plan premium.
Where is Navitus MedicareRx available?
The service area for Navitus MedicareRx includes all 50 states, including Puerto Rico, the U.S. Virgin
Islands, and Guam. You must live in the service area to join Navitus MedicareRx. If you reside outside the service area, you are not eligible to enroll in Navitus MedicareRx
Please contact your employer group if you plan to move out of the service area.
It is also important that you call Social Security if you move or change your mailing address. Existing
members can find phone numbers and contact information for Social Security in Chapter 2, Section 5 of your
Evidence of Coverage (EOC). Potential enrollees, contact your employer group for a copy of the Evidence of Coverage.
Who is eligible to join?
You, your spouse, and dependents are eligible to join if you qualify for your plan’s Medicare retiree coverage
through Navitus MedicareRx; you are enrolled in Medicare Parts A and B; and live in the service area. Your
premium for Medicare Parts A and B must be paid to keep your Medicare Parts A and B coverage and to remain a member of this plan.
How do I know which medications the Navitus MedicareRx Formulary covers?
The Navitus MedicareRx Formulary lists drugs selected to meet patient needs. Navitus MedicareRx may
periodically make changes to the Formulary. In the event of CMS-approved non-maintenance changes to the
Formulary throughout the plan year, Navitus MedicareRx will notify you.
Does my plan cover Medicare Part B or Part D drugs?
Navitus MedicareRx does not cover drugs covered under Medicare Part B as prescribed and dispensed, although the supplemental coverage benefit provided by your Employer Group will pay secondary to
Medicare Part B on select items such as diabetic testing supplies (review the Formulary to confirm coverage).
Generally, we only cover drugs, vaccines, biologics, and medical supplies that are covered under the Medicare Prescription Drug Benefit and that are on the Formulary. The drugs on the Drug List (Formulary) are selected by Navitus MedicareRx with the help of a team of doctors and pharmacists. The list must meet specific requirements set by Medicare. Medicare has approved the Navitus MedicareRx Drug List. The
supplemental portion of your plan covers some additional drugs that are not typically part of the standard
Medicare Part D formulary.
What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a service Navitus MedicareRx offers. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not
to participate, but it is recommended that you take full advantage of this covered service if you are selected.
There is no cost to you to participate in the MTM Program. If you have questions concerning our MTM Program please contact our Navitus MedicareRx Customer Care number on the back cover. For additional information regarding Medication Therapy Management, please refer to Chapter 3, Section 10, of your Evidence of Coverage.
Please call Navitus MedicareRx for more information about this plan
Navitus MedicareRx Customer Care: Navitus Customer Care and reference ID: MRXPSM at 1-855-213-1106 or 920-225-7014 (local), 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day.
Pharmacies can call Navitus MedicareRx 24 hours a day, 7 days a week. Navitus MedicareRx Member Portal:
• Current members: You may access our member portal by going to www.Medicarerx.navitus.com, click on Members, then Login
• New members: Once you receive your ID card, first time users can register at www.Medicarerx.navitus.com for access to the member portal.
• Potential enrollees, contact your employer group for the materials For more information about Medicare, call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Calls to these numbers are free and you can call 24 hours a day, 7 days a week. Or visit www.medicare.gov.
Navitus MedicareRx (PDP), offered by Dean Health Insurance, Inc., is a prescription drug plan with a
Medicare contract. Enrollment in Navitus MedicareRx depends on contract renewal.
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