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Prior Authorization Team


Main Line









Mailing Address

Navitus Health Solutions LLC

Attn: Prior Authorizations

1025 West Navitus Dr., Ste. 600

Appleton, WI 54913

Frequently Asked Questions

We are dedicated to our members. Your satisfaction and health is our top priority. Getting the prescriptions you need is important to us, and we are here to help you.

What is Navitus Health Solutions?

Navitus Health Solutions is a pharmacy benefit manager. We provide cost-effective prescription drug benefits for our clients and their members. Our mission is to improve member health and minimize their out-of-pocket costs.

What is a pharmacy benefit manager?

A pharmacy benefit manager (PBM) processes and pays prescription drug claims for its members. It contracts with pharmacies and builds and maintains drug formularies. A PBM also negotiates discounts and rebates with drug manufacturers.

I’m new to Navitus; do I need to change to a new pharmacy?

Most often, you will be able to continue to use your current pharmacy. There are more than 64,000 pharmacies in the Navitus network. Please provide your ID card information to the pharmacy when you fill a prescription. This will ensure you pay only the member out-of-pocket expense for your prescription.

Where can I search for Navitus network pharmacies?

A complete list of pharmacies is available in the Member Portal. If the pharmacy you currently use is not listed, please contact Navitus Customer Care toll-free at the number listed on your pharmacy benefit member ID card to confirm whether your current pharmacy is participating with Navitus.

How do I determine if a particular drug is covered? How do I determine what my copayment will be for this drug?

Your formulary (preferred drug list) is available in Member Portal. The coverage associated with each drug is noted on the formulary. Also included is information regarding which drug products are subject to prior authorization and/or quantity limits and drugs that are part of the RxCents Tablet Splitting Program. The formulary does not specifically indicate the dollar amount members can expect to pay for each drug product. The formulary document does not list every covered medication. See your Schedule of Benefits for more information.

How do I fill a prescription when I travel for business or vacation?

If you are traveling and require the dispensing of covered drugs, the following policy applies:
If traveling for less than one month:

  • Any participating pharmacy can arrange for an additional one-month supply to be taken with you. A copayment or coinsurance will apply to each month's supply;
  • You can request that your participating pharmacy mail a one-month supply to you at the address where you will be staying.
If traveling for more than one month, but within the United States:
  • You can request the participating pharmacy located in the area where you will be traveling to request your current pharmacy to transfer your prescription order.
  • You can request that your physician write an additional prescription order to be taken with you during your trip, with the intention that this prescription will be dispensed at a participating pharmacy located in the area where you will be traveling.
If traveling for more than one month outside the United States:
  • Please contact Customer Care toll-free at the number listed on your pharmacy benefit member ID card for information regarding the dispensing of covered drugs while out of the country.

How do I request reimbursement for pharmacy claims?

A member can make a request for reimbursement by completing the Direct Member Claim Form (PDF). You will be reimbursed directly for covered services up to the Navitus contracted amount. All requests for member reimbursement should be directed to the following address:

Navitus Health Solutions, LLC
Operations Division - Claims
P.O. Box 999
Appleton, WI 54912-0999

Who do I contact if I have general questions about my pharmacy benefit (e.g. eligibility in system, claims questions, request for replacement ID card, etc.)?

Please contact Customer Care toll-free at the number listed on your pharmacy benefit member ID card for questions about your pharmacy benefit.

When is Navitus Customer Care available?

24 hours a day, 7 days a week (closed Thanksgiving and Christmas Day)

How do I request an exception to coverage or medication appeal information?

Please contact the Customer Care toll free number listed on your pharmacy benefit member ID card or call Navitus Customer Care at 844-268-9789. They will provide further direction based on your benefit plan.

What is Step Therapy?

Step therapy is a formulary tool used to manage high-cost medications while improving health. When a medication requires step therapy, you are encouraged to try a less costly, clinically equivalent drug first. After trying this therapy, you can work with your prescriber to decide what is best for you.

You and your prescriber may find that the lower cost medication works well. If the medication isn’t working or your need is medically necessary, please ask your prescriber to contact Navitus.

Why Does Navitus Use Step Therapy?

Step therapy is an effective tool for ensuring that you receive safe, effective, high-quality medications at a lower cost.

How Does Navitus Decide What Medications Need Step Therapy?

Navitus uses a Pharmacy and Therapeutics (P&T) Committee to make all drug therapy decisions, including step therapy. They evaluate the safety and efficacy of a product, including clinical practice guidelines, based on available medical literature.

Priority is put on current U.S. Guidelines, which:

  • Acknowledge any potential conflict of interest
  • Describe the methodology of guideline development
  • Emphasize inclusion of peer-reviewed publications and evidence-based research
  • Incorporate widely-accepted medical practice
When higher-quality guidelines are unavailable, we consider others which:
  • Come from organizations outside the U.S.
  • Focus primarily on expert or consensus-based opinion
  • Lack any of the areas mentioned above
The P&T Committee considers cost only after it makes the clinical determination. Once the medication is evaluated, if a lower cost alternative exists, a step therapy protocol is set up.