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Pharmacy FAQs

At Navitus, we value the relationships that we have developed with our pharmacy providers and realize the importance of a strong, healthy, supportive rapport. Following is a list of frequently asked questions from pharmacies. For even more information, including the pharmacy handbook and client-specific information, click on the pharmacy login button.

Where can I find drug prior authorization forms?
Prior authorization forms are easily accessed via the Pharmacy Portal.
How long does a drug prior authorization review take?
All prior authorizations are reviewed within two business days of providers submitting all necessary information. Navitus Prior Authorization Specialists will promptly notify providers of any adverse decisions and assist with expediting the patient’s therapy to a formulary drug.
Who decides which drugs are included and excluded from the Navitus Formulary?
Decisions on which drugs are included or excluded from the Navitus formulary are made by the Navitus Pharmacy & Therapeutics (P&T) Committee, and are based on each drug’s effectiveness, side-effects, interactions and cost/value. The Committee is comprised of prescribers and pharmacists representing a broad range of clinical practice and expertise. The Committee meets quarterly to review new drugs and drug classes, as well as changes in drug indications.
How can I provide feedback about a communication I have received from the Navitus Clinical Department?
Contact Navitus Customer Care toll-free at 844-268-9789.
How can I join Navitus’ pharmacy network?
Contact the Pharmacy Network Department for information on joining the Navitus pharmacy network. They can be reached by email at providerrelations@navitus.com or by phone at 608-298-5775.
Once the contract request is faxed, how long until it is mailed out?
Please allow 2-3 business days for the contract to be sent. If you prefer the contract(s) to be faxed, please let us know at the time of request.
When can we process claims after the contract is mailed back to Navitus?
Please allow 5-7 business days for an independent contract and 7-10 business days for a chain/PSAO contract before adjudicating Navitus claims.
How can I change my pharmacy’s address and/or Tax ID number?
Update pharmacy information with NCPDP. Navitus receives a monthly file from NCPDP and updates our systems accordingly. Submit your update to NCPDP by the 15th of the month in order for it to be updated on the next monthly file load.
What do I do if a customer states the amount charged for his or her prescription is incorrect?
You may contact the appropriate call center below for verification of the patient pay amount:
Navitus Customer Care for Commercial Members  844-268-9789
Navitus MedicareRx (PDP) Customer Care  866-270-3877
Texas Medicaid/CHIP Customer Care   877-908-6023
What is the member ID number and format?
Member ID numbers and formats are unique for each group. Please refer to the member ID card for exact format.
Which BIN number do I enter to adjudicate the claim?
Please login to the pharmacy portal and refer to the Payer Sheets.
Does Navitus provide a website for pharmacies?
Yes, pharmacies may login to the Pharmacy portal here. This site contains payer sheets, news bulletins, updates/alerts and much more!
Who do I contact for payment/remittance questions?
Contact the Navitus Pharmacy Help Desk at 608-298-5777 or via email at payments@navitus.com.
Who do I contact if I want to file a dispute or appeal?
Contact the Navitus Pharmacy Help Desk at 608-298-5775 or via email at providerrelations@navitus.com.
How can I file a complaint about Navitus?
A verbal complaint may be filed by contacting the Navitus Pharmacy Help Desk. A written complaint may be submitted to the following address:

Navitus Health Solutions, LLC
Pharmacy Network Department
1025 West Navitus Dr.
Appleton, WI 54913
What are some common reject codes and the process to follow if received?
Contact the Navitus Customer Care at 844-268-9789 if you receive the following:
 
  • Missing/Invalid cardholder ID-reject 07
  • Missing/Invalid Date of Birth-reject 09
  • Missing/Invalid Group Number-reject 06
  • Invalid Day Supply-reject 19
  • Refill to Soon- reject code 79
  • Invalid NDC (National Drug Code)-reject 21
  • DUR- Reject 88
What should I do to resolve an exclusion?

Pharmacy and Practitioner Exclusion Troubleshooting

Background:
Navitus Health Solutions regularly monitors lists which may indicate that a practitioner or pharmacy is excluded from providing services to a government program. This may include Medicare, Medicaid or any payers who are participating in government programs. Navitus will flag these excluded practitioners and pharmacies to reject claims from processing.

Many Medicaid programs also consider a pharmacy or practitioner to be excluded if that pharmacy or practitioner is excluded from any other State Medicaid Program. While one Medicaid program may not list all other state exclusions on its own list, the laws of that state automatically include other state exclusions.

Exclusion has a variety of causes including fraud, licensing issues, enrollment errors, or other reasons. The reason for exclusion may not be given. Navitus does not know the reason for exclusion and does not regulate exclusion. This is done at the State or Federal level.

To resolve an exclusion, the practitioner or pharmacy must contact the source(s) responsible for its exclusion. Navitus cannot remove the exclusion. Navitus also cannot process claims until the pharmacy or practitioner is cleared by the excluding entity.

Suggestions for Resolution:

  • Review license(s) to ensure that any license is free of restrictions or disciplinary actions that may trigger exclusion
  • Contact the excluding entity
  • Medicaid (by State)
    • Contact each State Medicaid program that has a listed exclusion for the practitioner and/or pharmacy
  • Ask about the reason for exclusion and your options for resolving it
    • Verify that the excluding entity has the correct pharmacy or practitioner
    • Verify the length of the exclusion

FAQ's:

  • If a State Medicaid Program says a pharmacy or practitioner is not on the exclusion list in the given state, why is it still being excluded by Navitus?

    If that State Medicaid Program has a law or statute that prohibits other state Medicaid exclusions, the other states’ Medicaid exclusions would also apply. A state will generally only list the pharmacies or practitioners it has investigated and excluded. A state will not list other states’ exclusions.
     
  • If a State Medicaid Programs says an excluded practitioner is not prohibited from prescribing, why isn't Navitus processing claims prescribed by the practitioner?

    Prescribing is part of medical practice and is permitted under a practitioner’s state license. A practitioner may still be licensed, which allows prescribing. If the practitioner is also excluded, exclusion is a separate sanction. Even if the practitioner can prescribe under a state license, the exclusion prevents payment for the claims.
     
  • How long does the exclusion last?

    This varies based on the reasons used to exclude the practitioner or pharmacy. Medicare exclusions are usually no less than 5 years, with the length of exclusion listed on the OIG sanction. Medicaid programs may not list the length of exclusion.
     
  • How often are exclusion lists updated?

    OIG and GSA exclusion lists are updated monthly. Most Medicaid programs are updated monthly with some delays. Exclusion lists usually show the effective date of the exclusion but may not always show the end date. When an end date is reached, the excluded pharmacy or practitioner is usually removed from the list.
     
  • If a pharmacy that was excluded is purchased by a new owner, will that pharmacy remain on the exclusion list?

    It is likely that the pharmacy name will remain on the list until the new owner works with the appropriate entity to clear the exclusion.