Navitus Health Solutions

This company covered my medication at $50/month until the generic came out a few months ago. Once the generic version became available, they no longer covered the brand name. This would be fine if there was not a significant shortage of the generic medication. I cannot find the generic medication anywhere near where I live. Still, they will not cover the name brand so that I can continue taking my medication. I will not be able to afford to eat for the next week because I have to spend $150 on a 30 day supply of medication. This company does not care about your quality of life, it's only about money for them. Run far away from this company. Find one that actually cares about your needs.

All of a sudden, Navitus is requiring a preauthorization on Ozempic, a medication I have taken for diabetes for several years. This company is only about MONEY, and does not seem to care about patients. They will allow only a one month refill at a time, although I always got 3 months through Express Scripts. To make matters worse, they will not allow me to refill my script until the 4th dose for the month has been taken, and that leaves me 5 working days to get my meds. This is an additional problem because the 2mg Ozempic is being taken as a weight-loss drug although it was developed for diabetics, and it sometimes takes me DAYS to find the 2mg in stock somewhere. I am really tired of their rules which do not benefit customers, and will change insurances as soon as possible to a company that does not use Navitus. I have been told that this will take days to resolve, so I will be at least 4 days overdue on my next dose. This company is horrible!

I have had two appeals from my doctor, and both have been denied. A prescription that I have taken for years is now not covered by my insurance. I want to get off of this insurance and switch to a company that cares about its clients. Why pay for insurance if you're denied prescriptions? I let everyone know how poor this insurance company is. The first chance I get, I'm taking my family off.

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below.Thank you for sending me the response from Navitus Health Solutions (Navitus) Their comments are within the quotation marks.“Navitus understands the plan participant’s position.”No, they do not If they did, they would abide by the determination of my physician that Tadalafil is found to be Rx of choice.“An Exception to Coverage denial letter as well as a Grievance denial letter were mailed to the plan participant advising of the clinical rationale considered in the denial decision(s).”Yes, they did.“Navitus Grievance Coordinator spoke with the plan participant to inform him of the next level Appeal rights according to his benefit plan guidelines.”Yes, a person claiming to be from Navitus phoned me, on or about June 7, 2016, I told him I want his comments in a traceable written form, email, or letter He has, to this date June 2016, NOT sent me the letter; this is in order to not to be accountable for his/their comments.“The plan participant was receptive to the information provided.”This is a lie No, I was not, receptive to the information provided.As noted, I told the alleged Navitus person that I want his comments in a traceable written form, email or letter.“A Navitus clinical pharmacist has reviewed the clinical documentation that was received from his prescriber’s office and has determined that the request still does not meet the criteria for coverage of a non-covered medication since the formulary alternatives to treat his diagnosis have not been tried.”As mentioned in my original complaint, (January 15, 2016) Tadalafil is approved as a formulary medication, and I stated the FDA news release (copy sent to Navitus) with the appropriate citations Ditto P&T committee guidelines for revision.In addition, the reply from Navitus, one month later (Dated April 2016) claimed the appeal has been denied because “the side effects and covered alternatives were not indicated.” This is the second capricious excuse Initially (March 3rd) the excuse was “this request has not been approved because this medication is a non-formulary medication” Apparently (and coincidently), Navitus Health Solutions does not know the definition of a formulary medication and changes right denial on whim.Furthermore, the prescribed medication, Tadalafil has been approved as a formulary medication, and I stated the FDA news release (which was attached to the letter to Navitus) with the appropriate citations“ request still does not meet the criteria for coverage of a non-covered medication since the formulary alternatives to treat his diagnosis have not been tried.”With FDA approval for off- label prescription for BPH, the side effects and covered alternatives were evaluated and Tadalafil is found to be Rx of choice It was also the determination of my physician that Tadalafil is found to be Rx of choice.Regards, [redacted]

Please be advised that my complaint lodged against Navitus Health Solutions has been resolved in my favor.Thank you for your assistance in this matter.Sincerely, [redacted]

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below Thank you for following up with Navitus Health Solutions I do not accept the response made by the business to resolve this complaint I quote from the response from Navitus Health Solutions “We believe the confusion may stem from the word “formulary”.There is no confusion about the term formulary Navitus Health Solutions has capriciously determined that this medication is non-formulary Apparently an unidentified panel (a “Pharmacy & Therapeutics Committee”) at Navitus Health Solutions has made this determination, directly contradicting my local physician, who has examined me and based on the examination (including history of drug tolerance) has determined this medication is the most appropriate.Navitus Health Solutions claim “This is industry standard for managed care plans to develop a formulary to address medical appropriateness of medications” is untrue Navitus Health Solutions may not consider this medication formulary however; other national pharmacy benefits managers have determined this to be formularyIn addition, I have multiple responses from Navitus, first it was “the side effects and covered alternatives were not indicated.” Then it was “this request has not been approved because this medication is a non-formulary medication” Now it is the definition of the term formulary.Again, thank you for following up with Navitus Health Solutions I do not accept the response made by the business to resolve this complaint Regards, [redacted]

This letter is in response to the follow up response to the complaint from Mr*** *** on behalf of his wife, *** (patient) originally submitted August 20, 2016. We reviewed the complaint and agree that the medication was rejected as non-covered under the patient’s policy. In
this case, the patient was prescribed medication in a dose that is not covered under the patient’s policy. The patient reported that the pharmacy stated it would need to secure an approval from the provider for the new dose. The pharmacy was also informed at the time of claim rejection that another dose was available to substitute along with the options to contact the prescriber or Navitus. The day and time of pharmacy claim rejection was also consistent with most prescriber office hours so the prescriber could be reached timely. This was a Tuesday during midday The patient elected to pay out of pocket for the medication rather than wait for the pharmacy to complete its processing or contact the provider. Coverage based upon medication dosage is a permitted and usual practice of pharmacy plans This is industry standard for managed care plans to develop drug coverage to address medical appropriateness of medications and provide cost benefits to the plan and its patients. Some doses of medication may be more costly. However, the same therapeutic outcome can be achieved through alternative doses at a lesser cost to the plan and patient. Navitus provides communication of these alternatives to the pharmacies in real-time messaging during claims processing to allow the pharmacies to swiftly respond to patients. Additionally, Navitus is available 24/to address medication concerns with pharmacies or prescribers including coverage and dose. The patient has filed a first level appeal to receive coverage for this medication and she has submitted a refund request for payment of this medication. This dose of medication remains non-covered under the patient’s plan. The patient has additional rights through her plan to further request coverage of the medication. This right is not available for refund requests. We are hopeful that the member seeks this option as we encourage all patients to fully exercise their plan rights. Navitus is required to follow the benefit plan of the client and the all state laws regarding appeals and grievancesWe will also reach out to the pharmacy to review the member’s concerns and confirm that all claims processing messages were received by the pharmacy. We hope this clarifies the process for determining coverage for Ms***’ medication. Although Ms*** chose not to wait for her prescription to be modified, we trust that this explains the reasons for the denial, the options and processes that pharmacies will take to resolve these situations, and her continued rights with her planThank you for the opportunity to share this explanationSincerely, Navitus Health Solutions *** ***, CHC Associate Director, Corporate Compliance

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear belowThey stated, "According to your pharmacy benefit plan, there are certain categories of medications that are excluded, such as nutritional or dietary supplementsSince Nicomide is classified as a dietary supplement, this is excluded from coverage." Isn’t the whole point of the Exception to Coverage form to obtain coverage for something that usually is not covered? So why would they just respond to that form by saying it’s not covered under the pharmacy benefit plan? The Navitus representative’s response just demonstrates their incompetence and the reasons for my frustrationsI obviously knew it was not covered when I was told that in my first phone call with them regarding this issueThey are just repeating the same things, and none of their excuses make any senseI was told the medication was not covered, and the whole point of the Exception to Coverage form was to obtain coverage for a medication that usually is not coveredI was told that if I have been on this for a long time, it will usually be covered once the form is filled out and sent to themFor them to just repeat that the medication is not on the formulary due to it being classified as a dietary supplement (that requires a prescription by the way) just goes to show that the form (that they requested) is pointless and they do not care about my health, my physician's professional opinion and expertise, nor the fact that this medication has worked for me for years! If they had the medical knowledge, they would know that this medication, whether it is classified as a dietary supplement or not, is actually used to treat a real medical condition, and it has successfully done so in my case for yearsIf they had any knowledge about the FDA, they would know that the classification of this medication as a dietary supplement has to do with FDA regulation, and not necessarily what it is used for in real lifePerhaps if they knew how to search the medical literature, they would have found information about the effectiveness of this medication in treating certain medical conditionsFurthermore, my doctor’s office filled out the Exception to Coverage form multiple times at their requestThey still have not addressed the HIPAA violations that have taken place by them requesting my personal information that they do not needTheir rejection of the claim and the denied Exception to Coverage request was merely based on the fact that the drug is classified as a dietary supplementThey requested a lot of personal information about me that they did not even use to evaluate whether or not they were going to cover this medicationSince under HIPAA, they are only allowed to ask for and access the minimum amount of my personal information to do their jobs, and they don’t need my personal information to know that this medication is classified as a dietary supplement and is not on the formulary, they have violated HIPAA and my privacyMy privacy would not have been violated had they just told me in that first phone call that this medication is not covered, and no amount of information provided would change that factIt also would not have been violated, had they actually used the information provided by my physician’s office to recognize that this medication has worked for me for years, and I have tried other things that did not work, so perhaps they should make an exception in this case (Note: the whole reason for the Exception to Coverage form) and cover itThey did not do either of these thingsIn fact, they are continuing their violation of HIPAA by stating, “Per your denied Exception to Coverage letter, you have the option to appeal this recent denial.” If I were to appeal this, it would require me providing my personal information yet againSince the only reason for the denial is that this medication is classified as a dietary supplement, and my doctor and I are not the FDA, which is the organization that can change that classification, no information provided by us can affect the outcome of their decisionLast but not least, I am truly appalled that their clinical pharmacist would recommend a cholesterol medication for me when I do not have high cholesterol, and my medical condition has absolutely nothing to do with cholesterolShe could not provide any medical literature showing that this cholesterol medication is safe and effective for my conditionNone of their clinical pharmacists could name even medication on their formulary that is safer and more effective than the one I have been on and they are refusing to coverIn conclusion, this issue has not been resolvedThey are just repeating the same things that resulted in my initial complaint
Regards,
*** ***

We have reviewed the complaint that was forwarded to Navitus Health Solutions (Navitus) regarding denial of coverage for this plan participant’s medication, Navitus understands the plan participant’s position Navitus is a pharmacy benefit manager with the mission to provide cost-effective
prescription drug benefits for its clients and their membersOur clients require that we implement a prescription benefit program that is safe, clinically appropriate and cost-effectiveA Pharmacy and Therapeutics (P&T) Committee, composed of independent physicians, nurses and pharmacists, makes decisions on which drugs are available for coverage and ensures that options are available for brand alternatives and generics Navitus has addressed this matter, in accordance with the benefit plan guidelines established by the plan sponsor, with an unfavorable outcome for the plan participant through both the Exception to Coverage and Grievance Hearing processes. An Exception to Coverage denial letter as well as a Grievance denial letter were mailed to the plan participant advising of the clinical rationale considered in the denial decision(s)Based on the dates all correspondence from the plan participant were received, Navitus is in compliance with all regulatory requirementsOn June 7, 2016, the Navitus Grievance Coordinator spoke with the plan participant to inform him of the next level Appeal rights according to his benefit plan guidelinesThe plan participant was receptive to the information providedOn June 7, 2016, the Navitus Grievance Coordinator also reached out to plan participant’s prescribing physician’s office to request clinical documentation that supports the plan participant’s request for coverageA Navitus clinical pharmacist has reviewed the clinical documentation that was received from his prescriber’s office and has determined that the request still does not meet the criteria for coverage of a non-covered medication since the formulary alternatives to treat his diagnosis have not been triedNavitus will mail the plan participant copies of all correspondence applicable to this case

We now have responded to our fullest capacity the role of contractor for the insuranceIt is possible that the member may remain dissatisfied with this response, but the claim(s) in question are processing correctly according the member’s pharmacy benefit plan. Thank you, *** ** ***, CPhTGrievance and Appeals CoordinatorNavitus Health Solutions*** *** *** ***
*** ** ***
*** ***Fax: 920-221-4678***

Update 9/5/2016Is our case similar to this?Medaus Inc vNavitus Health Solutions LLC :: *** *** & FilingsJul 29, Medaus Inc vNavitus Health Solutions LLCPlaintiff: Medaus IncDefendant: Navitus Health Solutions LLCCase Number: ***_____________________________________________________________________________...⇄ are in communication with other third party sources and class action attorneys to see if this is happening to othersAbove is a new lawsuit that was filed by another party for your informationIt all comes down to that we are paying approximately $2,000/month and for us to put out additional monies when my wife is in extreme pain is outrageousI also have seen some recent activity that there may be company monies spent on trips to some really nice locations, a forensic audit and discovery will tell the truthThis money for these trips have to come from somewhere, obviously customers like us

This letter is in response to the follow up response to the complaint from Mr*** *** originally submitted May 27, 2016. We recognize Mr*** preference to receive a prescription as he has described in his initial and subsequent correspondence. We have also issued Mr*** his appeal rights in the initial written denial communication. His written plan benefit information also communicates this information as Navitus explained to Mr*** on June 7, 2016. We believe the confusion may stem from the word “formulary”. Mr***’s claim that the FDA has approved the drug is correct. This is an FDA approved medication that can be issued according to federal law. However, Mr***’s plan benefits do not cover all FDA approved drugs, only those medications included on the plan benefit’s formulary. This is formulary is developed and managed by Navitus Health Solutions through our Pharmacy & Therapeutics Committee. This is industry standard for managed care plans to develop a formulary to address medical appropriateness of medicationsOn Mr***’s plan benefit formulary, it is not a drug of choice regardless of its FDA approval status. This is a permitted and usual practice of managed care plansWe hope this clarifies the term formulary and why Mr***’s plan benefit formulary does not allow coverage for his drug. Although Mr*** may not be satisfied with the formulary of the plan benefits he has chosen, we trust that this explains the reasons for the denial and his continued appeal rights with the planFurther discussion regarding Mr***’s complaint can be addressed through his appeal rights should he choose to pursue that optionThank you for the opportunity to share this explanationSincerely, Navitus Health Solutions *** *** *** Associate Director, Corporate Compliance

[redacted] Revdex.com Complaint: We have reviewed the above complaint, and Navitus Health Solutions (Navitus) understands the plan participant’s position. Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. Our...

clients require that we implement a prescription benefit program that is safe, clinically appropriate and cost effective. A Pharmacy and Therapeutics (P&T) Committee, composed of independent physicians, nurses and pharmacists, makes decisions on which drugs are available for coverage and ensures that options are available for brand alternatives and generics. There may be certain categories of medications that are excluded from the prescription benefit plan.  With regard to standards related to “minimum necessary” under HIPAA, Navitus is knowledgeable of these standards. While we understand that the member may be frustrated with questions about her healthcare, our practice is to ensure that all elements of any patient’s condition are taken into account when evaluating coverage of a medication for both the safety of the member and to ensure adherence to benefits. Navitus manages a clinical messaging system that includes information about members’ allergies to help prevent members being given drugs to which they are allergic. This system provides warning messages to pharmacies when they are processing a prescription the member may be allergic to, directing the pharmacist to double check the prescription in order to avoid the member suffering an allergic reaction. The use of this information is a patient safety function that clearly falls under the HIPAA exceptions for payment, treatment, and operations, and has helped to avoid life threatening reactions for Navitus’ members who were prescribed drugs to which they are allergic. While the member in this letter correctly identified that there was no connection between the request for approval of payment for the member’s preferred medication, there is nothing illegal about Navitus requesting information about the member’s allergies and using it to help improve the member’s safety with regard to future prescriptions when claims are processed. The member, of course, has the right not to provide the information if they so choose. With regard to safeguarding patient information under HIPAA, Navitus is aware of its responsibilities. We have confirmed account documentation of phone calls from the member as well as receipt of documentation from the provider. The information that Navitus has received has been appropriately tied to the member’s account to ensure its protection. Navitus has strong processes to monitor incoming documentation to prevent loss, compromise, or inappropriate handling. Navitus is currently addressing this matter with the participant and informing her of the appeal options that are available under her prescription benefit plan.

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.Thank you for sending me the response from Navitus Health Solutions (Navitus).  Their comments are within the quotation marks.“Navitus understands the plan participant’s position.”No, they do not.  If they did, they would abide by the determination of my physician that Tadalafil is found to be Rx of choice.“An Exception to Coverage denial letter as well as a Grievance denial letter were mailed to the plan participant advising of the clinical rationale considered in the denial decision(s).”Yes, they did.“Navitus Grievance Coordinator spoke with the plan participant to inform him of the next level Appeal rights according to his benefit plan guidelines.”Yes, a person claiming to be from Navitus phoned me, on or about June 7, 2016, I told him I want his comments in a traceable written form, email, or letter.  He has, to this date June  14. 2016,  NOT sent me the letter; this is in order to not to be accountable for his/their comments.“The plan participant was receptive to the information provided.”This is a lie.  No, I was not, receptive to the information provided.As noted, I told the alleged Navitus person that I want his comments in a traceable written form, email or letter.“A Navitus clinical pharmacist has reviewed the clinical documentation that was received from his prescriber’s office and has determined that the request still does not meet the criteria for coverage of a non-covered medication since the formulary alternatives to treat his diagnosis have not been tried.”As mentioned in my original complaint, (January 15, 2016).  Tadalafil is approved as a formulary medication, and I stated the FDA news release (copy sent to Navitus) with the appropriate citations.  Ditto P&T committee guidelines for revision.In addition, the reply from Navitus, one month later (Dated April 20 2016) claimed the appeal has been denied because “the side effects and covered alternatives were not indicated.”  This is the second capricious excuse.  Initially (March 3rd) the excuse was “this request has not been approved because this medication is a non-formulary medication”.  Apparently (and coincidently), Navitus Health Solutions does not know the definition of a formulary medication and changes right denial on whim.Furthermore, the prescribed medication, Tadalafil has been approved as a formulary medication, and I stated the FDA news release (which was attached to the letter to Navitus) with the appropriate citations. “…request still does not meet the criteria for coverage of a non-covered medication since the formulary alternatives to treat his diagnosis have not been tried.”With FDA approval for off- label prescription for BPH, the side effects and covered alternatives were evaluated and Tadalafil is found to be Rx of choice.   It was also the determination of my physician that Tadalafil is found to be Rx of choice.Regards,[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted] and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
[redacted]
To confirm:The concern that we have is that when we have "Extreme Pain" that needs to be treated right away that we are able to rely on the $2,000 monthly insurance premium. The feedback that we have received is that the urgent pain does not matter; what matters is what was negotiated ahead of time by Anthem, Navitus and Albertsons pharmacies. My wife has been teaching at the same school district for 28 years with little or no sick leave. "When she is in pain then it must hurt like hell!""These companies should not be able to do business in California; they are taking hard earned money and not providing a fair service!"

Please be advised that my complaint lodged against Navitus Health Solutions has been resolved in my favor.Thank you for your assistance in this matter.Sincerely,[redacted]

We have reviewed the above complaint, and Navitus Health Solutions (Navitus) understands the plan participant’s position. Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. Our clients require that...

we implement a prescription benefit program that is safe, clinically appropriate and cost-effective. A Pharmacy and Therapeutics (P&T) Committee, composed of independent physicians, nurses and pharmacists, makes decisions on which drugs are available for coverage and ensures that options are available for brand alternatives and generics. Navitus addressed this matter, in accordance with the benefit plan guidelines established by the plan sponsor, with a favorable outcome for the plan participant.  [redacted]Senior Grievance and Appeals CoordinatorNavitus Health Solutions[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.                                Thank you for following up with Navitus Health Solutions.  I do not accept the response made by the business to resolve this complaint I quote from the response from Navitus Health Solutions “We believe the confusion may stem from the word “formulary”.There is no confusion about the term formulary.  Navitus Health Solutions has capriciously determined that this medication is non-formulary.  Apparently an unidentified panel (a “Pharmacy & Therapeutics Committee”) at Navitus Health Solutions has made this determination, directly contradicting my local physician, who has examined me and based on the examination (including history of drug tolerance) has determined this medication is the most appropriate.Navitus Health Solutions claim “This is industry standard for managed care plans to develop a formulary to address medical appropriateness of medications” is untrue.  Navitus Health Solutions may not consider this medication formulary…however; other national pharmacy benefits managers have determined this to be formulary. In addition, I have multiple responses from Navitus, first it was “the side effects and covered alternatives were not indicated.”  Then it was “this request has not been approved because this medication is a non-formulary medication”.  Now it is the definition of the term formulary.Again, thank you for following up with Navitus Health Solutions.  I do not accept the response made by the business to resolve this complaint.
Regards,
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
I did have a conversation with them again as they stated, but the issue is still not resolved. They are still not paying for it even though I am not using the medication as a dietary supplement. It's for a medical condition. They want me to appeal it again through them just so they can deny it again. Then they said I can appeal it through my employer. It has been about 2 months that I have been without my medication. I don't think any response from the business is going to resolve this issue at this point.
Regards,
[redacted]

Thank you for letting Navitus submit our findings regarding the above complaint.  We have reviewed the additional complaint from the member regarding her concerns that resulted from her rejected and subsequently denied claim for Nicomide.  We have reviewed all of the calls and documentation.  We spoke to this member on Wednesday, March 16th to discuss with her what we found while reviewing these calls and addressed the other concerns she listed in her complaint.  Points of concerns discussed:·         We explained that edit message wording made it difficult for the call center agent to know the reject reason and what the member’s options were.·         We explained that Nicomide is a plan exclusion as indicated in her Summary Plan Document.  ·         We explained our knowledge of and compliance with HIPAA policies and assured her that all information we requested/received is securely attached to her account and all information requested was relevant to her denial. ·         We explained to the member her rights to appeal and the process requirements. With her permission, we submitted the complaint to the Revdex.com as a request to initiate the Appeal process. We offered to send the member all of the documents related to her case so if she decided to pursue a 2nd Level of Appeal through her employer, she could determine which documents she would be comfortable sharing.  All information that is relevant to this case was mailed to her on Thursday, March 17th.Our call with the member was very productive. Member was given a direct contact to call at Navitus if she has additional more questions or concerns. [redacted]TGrievance and Appeals SupervisorNavitus Health Solutions1025 West Navitus DriveAppleton, WI 54913[redacted]