ComplaintsforNavitus Health Solutions

• Initial Complaint

  01/31/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My wife is a type 2 diabetic, she's been on various inject-able and oral medications for her entire adult life. She takes ******* now instead of **************************** contracted with Navitus health solutions. The contract is designed to reduce the plan's utilization which is a polite way of saying make getting needed medications more difficult to deter people from purchasing them and save the insurer $$$.Each year something happens. A computer error, a missing fax, something and Navitus somehow forgets that my wife is a diabetic. We have to go through a cycle again to reprove her diagnosis. This involves a doctor visit just for that purpose and many hoops takes about 3 months and costs us ~$2000 out of pocket. Navitus does it's best to make this process difficult. They refuses to provide a form for the doctor to complete on which she could attest to my wife's condition or to accept faxed copies of her health records. Rather they require the doctor to re-issue prescriptions with a special diagnostic code electronically. This means making an appointment ***** days out to see the Dr solely to ask her to resubmit a prescription again.With the background out now let me get to the problem. We anticipating this again and called in December. We were told very clearly Don't worry this won't happen again we see the diagnostic code on the prescription and we also see an override code since this happened to you last year. I asked for this in writing and was told they would send a letter, it never arrived. My wife attempted to fill her prescription on Saturday and we had to pay ~$900 out of pocket. I've been battling the *** for the last 3 days and was told yesterday in essence yeah we're stuck. call the Dr, make an appointment and in ***** days we'll cover it again. In the meantime don't stop taking the drug you need but also we aren't going to pay for it.. Do they think my wife grew a new pancreas over the new year's holiday?

  Business response

  02/09/2023

  Please see attached response. 

  This letter is in response to the complaint from *************************** regarding his wife ******* prescription coverage for Ozempic. In this complaint, the member is upset that Navitus has a diagnosis restriction edit in place to receive this medication.

   

  Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug

  benefits for its clients and their members. Mr. and ************** benefit plan provider is ********** of California (UCA). The members prescription benefit plan through UCA 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. They also will recommend utilization management criteria if a medication has a risk to be used inappropriately.

  The requested medication has what is called a restricted diagnosis (RDX) edit that applies. This is a new edit that was put into place October 1, 2022.  Member was given a 3-month transition period, however when this transition was up, it is required that the provider submit all prescriptions for Ozempic to the pharmacy with a diagnosis code for the claim to pay.  Despite multiple contact attempts by Navitus, the pharmacy and the member, provider has not sent in a prescription to the pharmacy with the appropriate diagnosis code, which did not allow ************** claim to pay appropriately.  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.  We then reached out to ************** and let them know about the override. 

  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 and the next steps in exercising the rights with the members plan. Thank you for the opportunity to share this explanation.

   

  Sincerely,

   

• Initial Complaint

  01/03/2023

  Complaint Type:

  Delivery Issues

  Status:

  Answered

  More info

  I want my doctor's ****** to be respected and for my medication, that I need bc I am in pain, approved. My Neurologist prescribed a medication that would help with my restless legs and arms. I was provided a 5 day sample while waiting for the medication to come. However, Navitus, denied my medication. They denied frequently despite me telling them that I am in pain and that this medication worked. I already take ropinirole and gabapentin. Those medications are NO longer working. They wanted me to take opioids. Opioids are highly addictive and I AM ALLERGIC to them. They refused to listen to reason. THEY REFUSED to listen to my doctors recommendation. He responded to them every single day last week despite him being on vacation. He filed numerous appeals and answered their questions. They didn't even have the curtesy to inform me via a phone call...despite the fact that I am in PAIN.

  Business response

  01/10/2023

  Hello,  Please see attached letter response.  Thank you. 

   

  ***************************, PharmD, BCPS

  Supervisor, Grievance and Appeals

  Navitus Health Solutions

• Initial Complaint

  12/06/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I switched insurance to Navitus (with ***************** UC Care) in March 2022. My medication is Estrogel ****%. My doctor requested continuing coverage for me for this critical medication. Navitus twice denied the continuing coverage, first an outright denial, then an appeal. This is despite my doctor ******************* writing a letter, and making two phone calls that either I have tried all the formulary alternatives, or, that I shod not take one of the formulary alternatives (oral pills). I cannot take the pills due to prior diagnosis of Migraine with Aura (linked to stroke risk), history of stroke in family. Also I tried the once a week patch and it made me nauseous. I felt nauseous after heavy exercise. The literature indicates that the patch is not good for women who heavily exercise as it releases too much estrogen at once. Navitus is refusing my continuing coverage despite my meeting all their criteria for exceptions to formulary. I will escalate this to the federal government if Navitus continues to deny my continuing coverage for Estrogel daily application. Thank you.

  Business response

  12/13/2022

  Hello, please see attached and reach out with additional questions. 

  Thank you,

   

  ***************************, PharmD, BCPS

  Supervisor, Navitus Grievance and Appeals

  Customer response

  12/15/2022

  [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 ********.
  
  However, the attached letter from Navitus is not what solved the issue. What soled the issue is the following. I called Navitus headquarters directly and eventually spoke to **************************, who has the title of

  Sr. Vice President ***** Chief Pharmacy Officer *************** listened to me, agreed Navitus in its most recent letter to me (dated October 10) had failed to acknowledge the formulary options I had tried, and my doctor's second phone call asking for the exception. I sent **************** some scientific information further supporting my case that the formulary options were not appropriate for me. Within 2 days, *************** reported back to me that Navitus had granted the exception for my continuing medication. Thank you, ***************************

• Initial Complaint

  11/22/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Navitus Health solutions is blocking me from getting my prescription my dr ordered. They are giving a error diagnosis code or the reject but wont deny the meds, so that my pharmacy can proceed with my secondary which will pay. If Navitus doesnt cover the meds for my diagnosis then they should deny it properly and not block me from my meds, that my dr felt I needed.I had to spend ******* for my meds because of the block. I have called many times to Navitus filled a grievance and havent heard anything from them. This started in October and I have called and talked to many supervisions, they said they are allowed to block my prescriptions according to *** regulations.

  Business response

  12/02/2022

  BBB of *********
  Attn: *************************
  10019 ****************.
  *********, ** 53214
  
  RE:  Complaint 18452302
          First Response
  
  Dear ********************,
  
  This letter is in response to the follow up response to the complaint from **************************  We reviewed the complaint and processed concurrently to a like complaint ************** has filed through the ******* ********** of ********* Services *****************************.In this complaint, the member is seeking coverage for a medication and has stated that Navitus has claimed we are permitted to block her prescription according to *** regulations.
  
  Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. We are not the members insurance. Ms. ****** benefit plan provider is The School District of ******* County ******* (SDCC).
  It is also important to clarify the role of the *** in this scenario. *** is involved in the clinical approval and use of medications. The coverage denial under her plan benefit was issued because the requested drug has only been approved by the *** to treat and manage Type 2 Diabetes, and the prescription request from Ms. ****** prescriber does not meet that diagnosis criteria.  
  As part of the services that Navitus provides to SDCC,Navitus handled the Prior Authorization (PA) triggered by the enclosed Exception to Coverage (ETC)  Request dated November 4, 2022. The results of that PA are contained in the enclosed Denied ETC Audit Log as well as the Prior Authorization Denial Letter. It is Navitus understanding that the first level of appeals for SDCC has been delegated to ********************************** (Allegiance) and would not be handled by Navitus. According to our last discussion with Allegiance, no appeal had yet been filed by ***************  Although the member may continue to remain dissatisfied with the coverage of her plan, she does have an additional right to an appeal which was described in the coverage redetermination notice to the member. 
  
  We hope this clarifies the steps we took and information we reviewed for this case.  We trust that this explains this members coverage, our diligence in responding, and the opportunities available to the member. Thank you for the opportunity to share this explanation.
  
  Sincerely,
  
  ***********************, CHC
  VP Corporate Compliance

• Initial Complaint

  10/30/2022

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  RE: Member Name: *************************** Date of Birth: 8/1/85 Case Number: ******** I filed an appeal with the Grievance and ****************** of Navitus Health Solutions on 8/11/22 (via fax and mail). They asked for additional information which I provided to them on 9/1/22 (via fax and mail). I received a letter dated 9/2/22 approving my appeal and a refund of $5,777.19; however, I have yet to receive the refund check. The Grievance and ****************** does not provide a telephone number, only the general **************** number. I have called 13 times and spoken with multiple people in multiple departments. I keep being told that they are reaching out to Accounting to see if my check has been generated and that they will call me back. They never call me back. I sent a fax to the Grievance and ****************** asking them to call me. They did not. I sent a letter to that department asking them to call me, and still nothing. I don't know what else to do. My appeal is approved and all they have to do is send me a check. I appreciate any help you can provide. Thank you, ***************************

  Business response

  10/31/2022

  Thank you for bringing this issue to our attention. This was due to a process oversight in which a handoff did not occur to initiate the recovery request.  However, our Grievance team has initiated this process to refund the claim the member and **************** is anticipating issuing the check no later than the week of 11/7/2022. 

  The member has been notified today directly by our Grievance team of the actions taken, the timeline, and we have verified her address to ensure the check is directed correctly.  The Grievance team will additionally be reaching out to her when there is confirmation that the recovery/refund process is completed and **************** has received.  At that time, a more specific date can be provided on the mailing date for the check.  

  We certainly apologize for the delay in this refund and will continue to reevaluate our processes for potential improvement. Thank you.

• Initial Complaint

  05/27/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I am covered through ********** of California by Navitus MedicareRX(PDP). My doctor prescribed TravatanZ to control my pressures after Glaucoma surgery. Navitus denied my request that they cover TravatanZ, indicating that they cover Travaprost, the generic. I appealed and still have no resolution. I am allergic to the preservative found in Travaprost (and not used in TravatanZ). I keep trying to appeal and get no answer or an answer that makes no sense. This is dangerous as without the medication I need I could go blind. It is hard to get in touch with the appeals department and they they promised 72 but do not follow up. This is a shoddy company that should not be allowed to practice in the medical field. The difference is $30 per month vs. >$800 if not covered.

  Business response

  05/31/2022

  Please see the attached response letter and accompanying support materials

• Initial Complaint

  05/04/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Navitus recently replaced our other pharmacy benefit company we have with **** ***************** in ********* **. When I tried to get my prescription refilled, the pharmacist indicated I needed to pay almost 3 times what a paid a few months ago. Thinking there was an error, I tried to reach out to Navitus through Anthem and we could not get an answer to our phone call. Then I tried several times calling Navitus on my own and still no one answers my call.

  Business response

  05/05/2022

  
  This letter is in response to the follow up response to the complaint from ***********************.  We reviewed the complaint and had no record of this member contacting Navitus.
  
  We reached out directly to the member to inquire about his concerns on 5/5/2022.  We learned that the numbers he was using were other Navitus numbers but not the ************* number designated by his ********************** plan.  This number of ************ was provided to him directly.
  
  The members expressed dissatisfaction that his drug copay was more expensive when compared to the previous year. The member filled his prescription in April for a drug that can be provided as a generic or brand medication.  The generic has a lower cost-sharing amount for the member.  The member received the brand medication as it was dispensed as written for brand in the prescription from the members practitioner.  This results in a higher cost sharing amount per the plan and formulary that the members employer has selected. 
  
  Navitus informed the member that there is an option to waive cost sharing through a process that enables the practitioner to submit a prior authorization requesting this waiver and documentation that the generic is not appropriate for the member.  ************** shared that this was not his responsibility and too costly in time and effort to deal with paperwork.  He requested escalation until his medication is approved.
  
  Navitus cannot change the members plan.  Navitus cannot change the prescription -changes to a prescription must be remedied between the member and prescriber. Navitus also cannot act in a medical capacity for the member and submit waiver documentation that must be completed by a practitioner.
  
  Although the member appeared to remain dissatisfied, he does have additional rights and options to reduce his cost sharing amount through use of the generic medication or working with the practitioner on the waiver process.  We are hopeful that ************** exercises one of these options. If Navitus receives a claim for the generic or the waiver documentation with prior authorization, Navitus will process these according to the plan coverage for the member.   
  
  We hope this clarifies the steps we took and information we reviewed for this case.  We trust that this explains the reasons for the difference in cost share and the opportunities available to the member. Thank you for the opportunity to share this explanation.
  
  

  Customer response

  05/06/2022

  Better Business Bureau:
  
  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 below.

   

   I would like to thank Navitus for their prompt reply of this complaint.

  Navitus, like many companies today, find it too easy to scam the public into paying extra and doing their paperwork for them.  For example, Navitus does not include that my Doctor, in his professional opinion believes the generic brand may not provide the best results for my condition.  He ordered I should use Synthroid, a life saving medication to help regulate my thyroid.

  Navitus also does not acknowledge that I offered a note from my doctor explaining the need for me to have non generic brands for this medication.  But what Navitus wants me to do in addition to providing them a note from my doctor is to fill out paperwork for an appeal, and then wait, and if I do not like their response do more paperwork.  This takes too much time when our previous prescription health care plan had me only paying $50 for the medication, Navitus wants me to pay $120, nearly 3 times what I had been paying. 

   Navitus tries to gloss offer these issues with comments like, "Navitus cannot change the members plan", "Navitus cannot change the prescription -changes to a prescription must be remedied between the member and prescriber", "Navitus also cannot act in a medical capacity for the member and submit waiver documentation that must be completed by a practitioner".

   Even though I never asked them or implied they should do these things, Navitus decides to state these deceitful comments to hide their corruption.  Navitus also misstates the phone numbers that I used.  Navitus was recently contracted by ***************** and when I contacted Anthem about this problem they tried to contact Navitus with the phone numbers Navitus gave them, but Navitus would not answer their call.  I used the phone numbers listed on their website and those numbers were wrong. Why would Navitus give the public wrong phone numbers and my health care provider wrong phone numbers? We can only pray the public, the **** and other HHS government agencies will see through this smoke screen and prevent companies like Navitus from taking advantage of the public's trust.

  
  Thanks again,
  
  *******************

  Business response

  05/08/2022

  Navitus Health Solutions has provided its response and the options available to the member.  Thank you.

*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. ↩