ComplaintsforNavitus Health Solutions

• Initial Complaint

  04/25/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  The lengh that my doctor has had to go through to get a prescription filled is unfathomable. Navitus is stalling intentionally on my prescription of ******** 8 days everyday on the phone with them and then my Doctor. I have an ****** Doctor that do this all day everyday and Navitus comes up with more and more for them to do. I have Prevea360 Health insurance through my employer and Navitus is who Prevea360 uses to preauthorize and or deny medication. I have a turned bowel tube. Linzess is something I take daily. Navitus is playing with my health!! And my $$. If this is not taken care of today I have to go into my ************** and have a procedure done tomorrow morning.

  Business response

  04/29/2024

  Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. The members plan through Prevea360 requires 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 is not the member call center for Prevea360. Navitus has received two calls from Prevea360 representatives, on April 23 and April ****************************************************** ******* provider.  Navitus has received one call from **************** on April 25, and she was referred back to her member call center with Prevea360 for further assistance.

  The requested medication requires prior authorization to be covered. For the prior authorization to be approved,certain criteria must be met, or clinical rationale must be given as to why each cannot be trialed. We received a prior authorization request on April 25,2024.  In the request there was not sufficient documentation to meet the criteria for the drug. As a result, Ms.******* request was denied. After a prior authorization is denied, the member can appeal this decision. Navitus Health Solutions does not handle the members appeals.  This appeal must be made in writing.  The information on how to appeal the decision is listed on the prior authorization denial letter or the member may additionally contact Prevea 360.

  We hope this clarifies the process and information we reviewed for the patients expressed concern and the additional rights regarding coverage. We trust that this explains the reasons for the initial denial, the options available to the member, and the next steps in exercising the rights with the members plan.

• Initial Complaint

  04/06/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  This is my 2nd complaint, I continue to receive wrong information. I am being told that a medication is being denied for not meeting restricted diagnoses of type 2 diabetes. Then I receive a letter that its being used for weight loss. Which is not accurate considering letters from my provider state its for cardiovascular disease. We requested an external review I was told by the appeals department this would be expedited and take 72 hours. I call back and I am then told it will take 45 days. This company can not give accurate information which I as the patient am suffering. You would think that if a patient suffered a heart attack and her providers are requesting a medication to reduce the risk of having another one we would get her this medication. Dealing with trying to get this approval is causing so much stress on myself. No patient deserves this. Navitus and Medica along with SSM need to remove this restricted diagnosis so the patient does not continue to suffer. In the long run its going to save a lot of $.

  Business response

  04/12/2024

  Based upon our review, ******* is covered on your plan formulary with a restricted diagnosis for Type 2 diabetes. There was an original request for ******* submitted by your prescriber on 02/03/2024 which listed that ******* as being prescribed to obesity and coronary artery disease. This request was denied on 02/08/2024 as a plan exclusion due to weight loss being excluded by your plan.
  
  There were several other requests submitted for ******* that were denied as they continued to have a primary diagnosis of obesity. An additional appeal for this denial of Ozempic was received on 03/28/2024. This request was reviewed and denied for not meeting covered diagnosis criteria on 03/29/2024.
  
  The second level review for Ozempic was received on 04/01/2024. This request is currently pending review. Per your request, we attempted to ask the ******************************* to expedite its review of Ozempic. We were advised that this did not meet criteria for expediting review. However, they advised a letter with further reasoning from your provider may be submitted for expedited review. The current standard time frame for a second level is up to 45 -days.
  
  Finally, on 04/09/2024 we escalated your request for exception of coverage of Ozempic to your plan. Upon review with your plan the decision was to let the denial of ******* stand based on the current diagnoses including the primary diagnosis of obesity and allow the second level review to proceed.

• Initial Complaint

  12/17/2023

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  My insurance for prescriptions is Navitus. I was on Wegovy for 6 months then the ** expired I couldnt find a dr that would agree to fill out all the documentation required by this company . I have been off the medicine and because of hormones and blood pressure issues they are denying my medicine that my doctor feels will help me. Navitus gives the wrong information on how to submit appeals. This company is prohibiting me from the medicine I need to live a healthy life with all their complicated forms and requirements.

  Business response

  12/26/2023

  I have attached a response letter from Navitus in regard to the members complaint. 

• Initial Complaint

  12/07/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Navitus deliberately declines claims with zero regard for the client. I've had migraines for 25+ years. That's a quarter of a century. Over the years I've tried multiple prescriptions to treat these. Most don't work at all or make it to where I can't work if I have to take them. My doctor submitted a request for Nurtec (not currently covered). The first time my doctor sent the fax, Navitus claims they didn't receive it. The 2nd time they declined it due to yhe 'wrong form submitted '. The 3rd time they said they couldn't process it b/c it needed 3 pieces of PHI and not two. (Um, it's their form- it was filled out completely and never asked for additional info). They said they needed my ss#. However, they wouldn't let me provide this nor our benefits *** department. It HAD to come from my doctor. The 4th time it was faxed they received it, sat on it a few days, then declined it saying there were other options. (Again, I've tried multiple over the years). My doctor filed an appeal. It was declined. When I called to ask why, I was told there were other options. COMPLETE ****.Ok, one of the options given was for Ubrevly. HOWEVER, I was told my doctor would need to fill out MORE paperwork for a 'prior authorization'. At this point, Navitus declines just to decline with no acceptable reason. I've gone to the same doctor for ALL OF MY LIFE. LITERALLY. He has been recognized as one of the best in his field as well as an expert with my medical needs.Navitus- DO YOUR JOB. Migraines are incredibly painful. Nurtec has been approved to not only treat but PREVENT some migraines. STOP MAKING PEOPLE JUMP THROUGH HOOPS. I'm sure most people give up b/c you deliberately make the process impossible. You are dealing with people's medical issues. You need to do better. Respect my ******* ******************************** and his medical expertise.

  Business response

  12/15/2023

  Please see the attached response letter in regard to the members complaint.

• Initial Complaint

  11/08/2023

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Answered

  More info

  I have a prescription for ****** that has needed prior authorization which I had my physician send in. I was told they havent received it and its going to take up to December 7th before its approved. I have had the authorization just a few months ago and it expired on Nov 4th with no notice or warning that I would need another one. I should not be starting and stopping this medication like this seeing that I am prediabetic. I would like this to be reviewed and approved without all the complications.

  Business response

  11/13/2023

  Hello,

  Please see attached response. 

  Thank you,

  ****

• Initial Complaint

  11/07/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  This is my second complaint, the first was filed on 01/31/2023. My wife is a type 2 diabetic, her current medication Ozempic is in short supply so the Dr. temporarily wrote a prescription for Rybelsus to keep her healthy while waiting resupply.Navitus again refused to fill this again saying that they weren't able to confirm the diagnosis. They previously responded to the 01/31/23 complaint with this "After being made aware of this situation, we were able to confirm diagnosis with provider and enter a lifetime override to allow ******* to pay while on formulary. "So she hasn't grown a new pancreas she's still diabetic. I was told there was nothing I could do, make another appointment wait 2 weeks to see the DR again and get a different drug or have the prescription reformatted. In the meantime I'm out $2,000 to keep her out of the ER.I mentioned this happened before and they indicated that it had not and they weren't aware of any BBB responses. I expect this to be a yearly event.

• Initial Complaint

  10/02/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  Have struggled and argued with this company for a bit now while they continue to deny paying for my meds and visits. I have been in contact with dhs numerous times at the direction of Navitus employees saying issue was a 2nd insurance. Dhs had it on their file there hasn't been one since end of July. I was told by navitus employee that dhs needed to send paperwork. Refused to give me a number where to send it. *** said they don't send anything out, just change it in computer which was updated in July. Said all Navitus has to do was look. And of course I'm still being denied. I can't pay for my meds because I'm on state insurance. I've filed a formal complaint with the ****************** also

  Business response

  10/06/2023

  Hello, please see attached. Thank you.

  Customer response

  10/06/2023

  [A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. 
  
  Regards,
  
  *************************
  

• Initial Complaint

  07/21/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  This insurance company keeps denying medication that is prescribed and gives me no information. They should be held responsible for other medical issues that come from them not approving meds that are prescribed.

  Business response

  07/27/2023

  Please see attached.  

  Thank you,

  Jacki 

• Initial Complaint

  05/02/2023

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  I feel like this company is not communicating with myself and my sons physician to approve the medication that he needs based on the medical work up provided. I feel like this may be done as normal business to not approve medical preauthorizations in order to discourage and save money despite the outcome or needs of the patient. My son had already gone through this entire process with our previous medical insurance to get him approved for growth hormone less than 3 months prior and due to their lack of care he is now completely out of medication because of what preferred medication they want to approve. Please contact me if there is any further information that I can provide. I dont want other parents or families to have to go through this unnecessary hassle because this company wants to save a buck.

  Business response

  05/03/2023

  Please see attached.  Thank you.

• Initial Complaint

  02/01/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I have a new medication ( farxiga ) and instead of my normal $5.00 co-pay I have to pay $70.00. I want this lowered to $5.00.

  Business response

  02/07/2023

  Please see attached response to complaint received. 

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩