Navitus Customer Guide: Enrollment, Claims, and SupportNavitus is a pharmacy benefits manager (PBM) that partners with health plans, employers, and other organizations to manage prescription drug benefits. This guide explains how Navitus enrollment works, how to file and track claims, and what support options are available for customers. It’s written for plan members, HR administrators, and anyone seeking clarity about using Navitus-managed pharmacy benefits.
1. What is Navitus and how it operates
Navitus is a PBM that focuses on transparent pricing and clinical management to control prescription costs while ensuring access to necessary medications. Unlike some PBMs that generate revenue through spread pricing and rebates retained by the PBM, Navitus emphasizes pass-through pricing models where possible, aiming to return negotiated discounts to plan sponsors and reduce conflicts of interest.
Key services Navitus provides:
- Formulary development and management
- Pharmacy network contracting and administration
- Prior authorization and step-therapy programs
- Clinical programs (medication therapy management, adherence programs)
- Claims processing and adjudication
- Cost containment and reporting
2. Enrollment: who, when, and how
Enrollment into a Navitus-managed pharmacy plan typically occurs through the member’s health plan, employer benefits enrollment, or a sponsor organization (e.g., union, association). Navitus itself does not usually enroll members directly; rather, members are enrolled in a health plan that uses Navitus as its PBM.
Steps for members:
- Confirm coverage: Check your health plan ID card or benefits materials to verify that your prescription benefits are administered by Navitus.
- Open enrollment or qualifying event: Enroll through your employer’s benefits portal, health plan website, or HR during open enrollment or after a qualifying life event (marriage, birth, loss of other coverage).
- Receive ID and welcome materials: After enrollment, you’ll receive a prescription drug card or your medical plan ID that includes Rx coverage details and Navitus contact information.
- Set up online access (optional but recommended): Create an account on Navitus’ member portal (if available through your plan) or access prescription benefit details through your health plan’s portal. Online access typically lets you view formulary, drug pricing, prior authorization requirements, and mail-order options.
Tips for administrators:
- Provide clear communications to employees/members about who the PBM is and how to find their Rx card.
- Coordinate timing between medical plan enrollment and Rx communication so members have cards before needing medications.
- Offer step-by-step guides for using online tools and mail-order services.
3. Understanding benefits, copays, and formularies
Formulary and tiers:
- Navitus manages formularies (drug lists) that categorize medications into tiers. Tiers affect member cost sharing — lower tiers usually mean lower copays or coinsurance.
- Formularies may include preferred generics, preferred brands, non-preferred brands, and specialty tiers. Some plans use coinsurance (a percentage of cost) rather than fixed copays.
Prior authorization, step therapy, and quantity limits:
- Prior authorization (PA): Certain medications require approval before coverage is granted. Your prescriber usually submits PA requests to Navitus or the health plan.
- Step therapy: Members may be required to try a lower-cost therapy before the plan covers a higher-cost alternative.
- Quantity limits: Limits on how much medication can be dispensed per fill to prevent waste or misuse.
Out-of-pocket cost drivers:
- Copays vs coinsurance
- Deductible status
- Whether a drug is on- or off-formulary
- Use of mail-order for 90-day supplies vs retail 30-day fills
4. Filling prescriptions: retail and mail-order
Retail pharmacy:
- Present your pharmacy benefit card at an in-network retail pharmacy. The pharmacist will submit a claim to Navitus for adjudication.
- If a drug is subject to PA or step therapy, the pharmacist or prescriber will be notified at the point of sale about any required actions.
Mail-order and specialty pharmacies:
- Navitus often partners with mail-order pharmacy vendors for 90-day supplies, which may lower per-fill costs and improve convenience.
- Specialty medications (complex biologics, injectables) are managed via specialty pharmacy partners with additional care coordination and prior authorization processes.
Tips to save:
- Use generics where appropriate.
- Switch to a 90-day mail-order supply for maintenance medications if permitted.
- Talk to your prescriber about therapeutic alternatives on the formulary.
5. Claims processing and adjudication
How claims work:
- Prescription is dispensed and pharmacist submits a claim electronically to Navitus.
- Navitus adjudicates the claim against the member’s benefits (eligibility, formulary, PA requirements, copay/coinsurance, deductible).
- The claim response indicates the member’s cost share and whether the medication is approved or requires additional steps.
- If a PA is required, coverage may be pending until the PA is approved.
Common claim outcomes:
- Paid: fully adjudicated and member cost determined.
- Rejected/denied: requires correction (e.g., invalid ID, coverage lapse) or is uncovered by plan.
- Pending PA: requires prescriber submission for prior authorization.
If a claim is denied:
- Contact the prescribing provider to confirm they submitted any required PA or documentation.
- Contact Navitus member services or your health plan for details on why the claim was denied and next steps.
- Ask about exceptions or formulary alternatives.
6. Prior authorization and exception requests
Submitting prior authorizations:
- Typically, the prescriber initiates PA requests through Navitus’ provider portal, fax forms, or by phone, depending on the plan’s procedures.
- Include clinical documentation to support medical necessity (labs, prior therapy history, diagnosis codes).
Appeals and exceptions:
- If PA is denied, prescribers and members can file an appeal following the plan’s grievance process. Urgent/expedited reviews may be available for time-sensitive medications.
- Medical exceptions: A prescriber can request an exception to the formulary when clinical reasons justify use of a non-formulary drug.
Timelines:
- Urgent requests often resolved within 24–72 hours.
- Standard requests typically resolved within a few business days, but timelines vary by plan and state regulations.
7. Support channels and resources
Where to get help:
- Member services phone number: Listed on your ID card and plan materials. This is usually the fastest way to resolve coverage questions.
- Online portal: Check drug coverage, estimated costs, and formulary information.
- Pharmacy: Pharmacists can often resolve billing/PA questions or advise on alternatives.
- Prescriber/provider support: Navitus provides resources for prescribers to submit PAs and manage claims.
- Employer/HR or plan administrator: For eligibility and enrollment issues.
What to have when you call:
- Member ID number from the Rx or medical ID card
- Prescription name, strength, and prescribing provider
- Pharmacy name and date of fill
- Any denial/error messages received
8. Common issues and how to resolve them
Lost/incorrect ID card:
- Contact your employer or health plan for a replacement card. Temporary Rx coverage info may be available via the plan’s portal.
Claim rejected at pharmacy:
- Verify member eligibility and ID. If eligible, ask the pharmacist to re-run the claim.
- If rejection persists, note the exact rejection code and contact Navitus member services.
Prior authorization delays:
- Ensure the prescriber submitted required medical documentation.
- Request an expedited review if medication is urgent.
High out-of-pocket cost:
- Confirm formulary tier and ask about generic or therapeutic alternatives.
- Request a formulary exception if medically necessary.
- Explore manufacturer patient assistance programs for specialty drugs.
9. Tips for maximizing benefits and lowering costs
- Use generics and preferred brand alternatives when available.
- Use mail-order for maintenance meds to access 90-day supplies and lower per-fill costs.
- Talk to your prescriber about step-therapy pathways to avoid interruptions.
- Keep prescriptions synced (align refill dates) to reduce pharmacy visits and risk of missed refills.
- Review annual formulary updates during open enrollment and plan accordingly.
10. For administrators: reporting and compliance
Reporting tools:
- Navitus provides utilization, cost, and performance reports to plan sponsors. These reports help identify high-cost drugs, utilization trends, and opportunities for savings.
Compliance:
- Ensure your plan documents reflect Navitus’ PA criteria, quantity limits, and specialty processes.
- Coordinate communication strategies for formulary changes, prior authorization updates, and member notices.
11. Frequently asked questions (short answers)
- Who do I call about a prescription denial? Call the member services number on your ID card.
- Can I use any pharmacy? Use an in-network pharmacy listed by your plan to get full benefits.
- How long does a prior authorization take? Urgent requests: often 24–72 hours; standard: a few days (varies).
- Are mail-order prescriptions cheaper? Often yes for 90-day maintenance supplies.
- Who files a PA—pharmacy or prescriber? The prescriber usually submits the prior authorization.
12. Final notes
Navitus functions as the PBM partner for many health plans and employers; members interact primarily through their health plan and pharmacies. Knowing how enrollment, claims, and support processes work reduces delays and surprises when managing prescriptions. If you have specific questions about your coverage, check your plan documents or contact the number on your ID card for plan-specific details.