Solutions
Clarity that Drives Better Decisions
Navitus offers a variety of pharmacy benefit solutions built on a foundation of true transparency. Our approach emphasizes collaboration and innovative strategies that drive to lowest net cost, improve patient care and enable clients to optimize the value of the benefit.
Purpose-built to Serve our Clients and Partners
Our pharmacy benefit solution is crafted to meet the unique needs of the people we serve.
Claims Adjudication
As a pharmacy benefit manager, we interact with many parts of the drug supply chain. We understand the systems we support and the benefits we manage enable a member to access important medications for themselves or a loved one. Because of this, we focus on ensuring they operate as expected.
Built from the ground up, our claims adjudication system is a single, fully redundant platform. Its suite of applications supports claims processing, eligibility, formularies, benefit plans and prior authorizations in addition to comprehensive safety and compliance edits for every claim. It supports real-time adjudication of prescription drug claims at the point of sale, regardless of the distribution channel to enable member access to a prescription.
For optimal availability, Navitus adjudication systems are continuously monitored, and outliers are immediately communicated. Dedicated team members ensure compliance with National Council for Prescription Drug Programs (NCPDP) and the Centers for Medicare & Medicaid Services (CMS) guidelines along with requirements that result from regulatory changes.
This is foundational to our ability to serve our clients and members well.
Formulary & Utilization Management
Traditional PBMs often make formulary and utilization management decisions to generate higher rebate values instead of driving to the lowest net cost for plan sponsors and members. This is because they keep a portion of rebates for profit and stand to benefit when drug prices go up.
We don’t.
We believe efficient formularies are clinically effective, limit waste and drive to lowest net cost. Our formularies and utilization management practices are designed based on clinical data to manage costs while maintaining high quality of care.
Pharmacy Network Management
Our pharmacy network strategy supports client goals and ensures access for members filling prescriptions by:
- Contracting tens of thousands of credentialed pharmacies spanning retail, mail and specialty
- Managing industry-standard network options for expanded access and greater savings
- Supporting use of owned or in-house pharmacies
- Partnering with clients in government programs business to meet requirements
These efforts are built upon our foundational, fully transparent and pass-through model. We do not create margin by billing clients more than we pay pharmacies. Our clients pay what we pay and immediately receive 100% of the discounts that we negotiate on their behalf. We empower clients to determine the most appropriate option to meet their needs.
Cost-plus Specialty Pharmacy
On average, just 2% of patients have complex, chronic illnesses requiring specialty medications, yet these drugs account for more than 50% of total drug spend. Specialty drugs are one of the largest cost drivers for plan sponsors and health plans. With new drugs entering the market each year, it can be challenging to both control cost and enable access to important treatments.
Our wholly owned subsidiary, Lumicera Health Services, is one of few cost-plus pharmacies in the nation, and it has a unique focus on specialty medications. While Navitus clients have a choice in what specialty pharmacy they choose, a majority choose Lumicera. Here’s why:
- Lumicera was built on a 100% transparent, pass-through model and was not built to generate significant revenue from rising specialty drug prices
- Clients only pay the invoiced actual drug acquisition cost, plus a flat patient-management fee and shipping
- Lumicera’s First In, First out (FIFO) inventory management ensures drug costs are never inflated
This commitment to keeping specialty medication costs as low as possible is coupled with exceptional patient care. Lumicera deploys a high-touch support model that supports patients with education, personalized guidance and ongoing assistance throughout their treatment journey. The Lumicera team is dedicated to improving specialty pharmacy care, one patient at a time, through leading cost and care management.
Medical Specialty Drug Management
Between 30-40% of a plan’s specialty spend is within the medical benefit. But that benefit and the structures in place were not designed to manage use of highly expensive specialty medications. This has resulted in total benefit cost trends increasing year over year as new, high-cost drugs come to market.
To meet the growing needs of our clients for capabilities in this space, Navitus Health Solutions assumed a majority investment in Archimedes, the market leader in specialty drug management, in 2024. By adding best-in-class technology, plan sponsors and health plans can improve oversight of medical specialty expenses and use clinical engagement services to find savings opportunities.
Member Enablement and Support Services
Navigating health care can be overwhelming and changes to benefits can be disruptive. That’s why we’re focused on making sure members feel supported and equipped to use the pharmacy benefit our clients have designed. This includes ensuring members understand the offering and are aware of their opportunities.
Our member support model includes:
- Personalized member transition support, including formulary transition support from staff clinicians
- Robust member portal, desktop and mobile app offerings
- 24/7 call center support with multiple translation services available
Real Stories. Real Impact.
At Navitus, we’re proud to partner with organizations and individuals who trust us to provide affordable, transparent pharmacy benefits.
Discover how Navitus can help transform your pharmacy benefits. Let’s start a conversation and create a plan that works for you.
Latest Insights
Our latest insights, testimonials and more:
Legal Ease: Key Legislative & Regulatory Updates Impacting Plan Sponsors in 2025
In this overview of our national Legal Ease webinar event, we highlight key federal and state developments shaping the conversation around PBM reform – and what they mean for your clients. …
Navigating the Drug Supply Chain: What You Need to Know
Before a prescription ever reaches a pharmacy counter, it has already moved through a complex ecosystem known as the drug supply chain. From manufacturers and wholesalers to pharmacy benefit managers (PBMs) and pharmacies, each entity plays a role in…
Real-world Data Demonstrates Successful Transitions from Humira to Biosimilars
Authors: Justin Arzt, PharmD; Agata Siwak, PharmD, MSBA; Marnie Wickizer, PharmD, AE-C, CDCES; Ryan Schmidt, PharmD; Robert Topp, RN, PhD; Matt Hustad, PharmD All authors are employees of Navitus Health Solutions. Abstract Adalimumab biosimilar adoption…
PBM 101: Why the Model Matters
In the pharmaceutical and healthcare industry, pharmacy benefit managers (PBMs) are conduits of expertise, analytics and savings opportunities, poised to deliver exceptional health care while driving down costs. They coordinate between drug manufacturers,…
Associate Resource Group Spotlight: Green Team
The Green Team believes that small changes lead to significant impact. Whether its reducing waste, conserving energy or implementing eco-friendly initiatives, they serve as an internal hub for expertise regarding environmental sustainability….
PBM 101: The Three PBM Business Models
In the pharmaceutical and healthcare industry, pharmacy benefit managers (PBMs) are regarded by the media as intermediaries between drug manufacturers, pharmacies, health plans and plan sponsors. But they’re so much more than that. PBMs act as conduits…
An Automated Approach to Diagnosis Verification of GLP-1 RA for Type 2 Diabetes Mellitus (T2DM)
This study examines the impact of implementing an automated point-of-sale diagnosis verification system for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) compared to traditional utilization management approaches….
Navitus to Remove Stelara® from Formulary July 1, 2025, Adds Biosimilars to Drive $120 Million in Savings
As the nation’s first 100% transparent, pass-through PBM, we continue to advance medication affordability by prioritizing upfront, real-time savings over rebated models….
Achieving Outstanding Results with Tailored Network Strategies
A medium-sized city in Michigan with 1,350 members was seeking ways to lower its pharmacy benefit costs, which were growing under its existing traditional pharmacy benefit manager (PBM). With its member covered by a two-tier, open formulary including…
