Prior Authorization Process
How does Navitus decide which prescription drugs should require Prior Authorization?
Navitus’ Pharmacy and Therapeutics (P&T) Committee creates guidelines to promote effective prescription drug use for each prior authorization drug. These guidelines are based on clinical evidence, prescriber opinion and FDA-approved labeling information. Some types of clinical evidence include findings of government agencies, medical associations, national commissions, peer reviewed journals, authoritative summaries and opinions of clinical experts in various medical specialties.
What is the purpose of the Prior Authorization process?
- Increase appropriate use of certain drugs
- Promote treatment or step-therapy procedures
- Actively manage the risk of drugs with serious side effects
- Positively influence the process of managing drug costs
How does my prescriber begin the Prior Authorization process?
A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. The request processes as quickly as possible once all required information is together.
If the submitted form contains complete information, it will be compared to the criteria for use.
If the submitted form does not have all of the needed information, the prescriber will be contacted to provide the information. If the prescriber does not respond within a designated time frame, the request will be denied.
A prescriber may notify Navitus by phone or fax of an urgent request submission. A decision will be made within 24 hours of receipt. The member and prescriber are notified as soon as the decision has been made.
Urgent requests will be approved when:
- A service delay could seriously jeopardize the member's life or health
- A prescriber who knows the member’s medical condition says a service delay would cause the member severe pain that only the requested drug can manage
- On weekends or holidays when a prescriber says immediate service is needed. The pharmacy can give the member a five day supply. The member is not responsible for the copay. During the next business day, the prescriber must submit a Prior Authorization Form.
(Note to pharmacies: Inform the member that the medication requires prior authorization by Navitus. Submit charges to Navitus on a Universal Claim Form. You will be reimbursed for the drug cost plus a dispensing fee.)
How does my prescriber submit a completed Prior Authorization form to Navitus?
|U.S. Mail||Navitus Health Solutions LLC
Attn: Prior Authorizations
1025 West Navitus Drive
Appleton, WI 54913
|Fax||1-855-668-8551 (toll free) - Commercial
1-855-668-8552 (toll free) - Medicare
1-855-668-8553 (toll free) - Medicaid
How will I find out if my Prior Authorization request is approved or denied?
The member will be notified in writing.
How can I get more information about a Prior Authorization?
Please contact Navitus Customer Care toll-free at the number listed on your pharmacy benefit member ID card.