Navitus Customer Care: A Practical, Expert Guide

Who Navitus Customer Care Serves and When to Use It

Navitus Health Solutions is a pharmacy benefit manager (PBM) that supports health plans, employers, government programs, and millions of members across the United States. If your prescription benefits card shows “Navitus,” Customer Care is your first stop for help with pharmacy claims, drug coverage questions, network pharmacies, prior authorizations, and savings opportunities. Support is designed for both members and providers, with dedicated workflows for each.

Customer Care is available 24/7/365 for most plans, which is critical when issues arise at the pharmacy counter outside normal business hours. Navitus’ network includes more than 64,000 retail pharmacies nationwide, so agents can typically find an in-network option within a few miles of most U.S. households. While specific plan rules vary, the Customer Care team is trained to interpret your plan’s formulary, cost-sharing, and clinical rules and to resolve common claim denials in one call.

How to Reach Navitus

Phone Support

Call the phone number printed on your Navitus member ID card for the fastest, plan-specific assistance. This routes your call to agents who can see your exact benefits, copays, and prior authorization requirements. TTY users can dial 711 to use the Telecommunications Relay Service. Have your Member ID, date of birth, and the prescription information (drug name, strength, quantity, and pharmacy name) ready to speed verification and triage.

Most lines operate 24/7, including weekends and holidays. If you’re calling from the pharmacy counter, ask the pharmacist to remain on the line—Customer Care can conference in to troubleshoot real-time claim edits, coordination of benefits, or NDC substitutions. For privacy, Navitus may require verbal consent from the member before discussing protected health information with a spouse or caregiver unless a HIPAA authorization is on file.

Digital Channels

Start at navitus.com and follow the Members link to the secure member portal. After creating an account with your Member ID, you can view claims, check drug coverage and estimated costs, look up in-network pharmacies, and access digital ID cards. Many plans also enable secure messaging with Customer Care through the portal for non-urgent requests.

If your plan offers the mobile experience, you can compare 30-, 60-, and 90-day fill options, locate preferred pharmacies, and receive alerts when a claim processes or a refill is due. Digital tools are especially helpful for price checks before visiting the pharmacy so you can avoid surprises and unnecessary back-and-forth.

What Customer Care Can Do on the Spot

Navitus agents can resolve many pharmacy issues without escalations. When a claim rejects at the register, they can see the reject code, apply plan-allowed overrides, and reprocess the claim with the pharmacist on the line. They can also verify your eligibility and COB (coordination of benefits) when you have more than one prescription plan, which is a common source of denials.

For coverage questions, the team can explain formulary tiering, identify therapeutically equivalent alternatives, and outline the prior authorization (PA) or step therapy steps if required. When needed, they can start a PA request with your prescriber or provide plan-specific forms and submission instructions.

• Real-time claims help: resolve ID/BIN/PCN issues, reverse and re-bill claims, correct days’ supply, or switch to a covered NDC.
• Benefit and cost clarity: confirm whether a drug is covered, its tier, expected copay/coinsurance, and any quantity limits.
• Pharmacy network navigation: find in-network options nearby, including preferred pharmacies that may lower your cost share.
• Prior authorization kickoff: send PA criteria to your prescriber and track status; provide next steps if a denial occurs.
• Vacation/emergency supplies: when plan-allowed, place temporary overrides for travel, lost medication, or dosage changes.

Benefits, Costs, and Savings Help

Customer Care can walk you through the cost differences between brand and generic drugs and help you ask your doctor about clinically appropriate lower-cost alternatives. According to FDA data, generics can cost 80–85% less than their brand counterparts on average, and many plans tier generics at the lowest copay. Agents can also identify whether your plan offers preferred products or therapeutic alternatives with similar outcomes but lower member cost.

Ask about 90-day supplies at retail or mail delivery if your medication is for chronic use. Many plans offer pricing efficiencies for 90-day maintenance fills compared to three 30-day fills, and some designate specific “preferred” pharmacies for the best price. Customer Care can compare options in dollars and cents before you fill, which helps you make decisions that balance convenience and cost.

Prior Authorizations, Exceptions, and Appeals

If your drug requires prior authorization, Customer Care will outline the clinical criteria and how your prescriber should submit documentation. For commercial plans, decisions typically occur within a few business days, with faster review for urgent cases; exact timelines depend on state law and your plan’s rules. If coverage is denied, they will explain the reason and your next steps, including exception requests or appeals.

For Medicare Part D plans administered by Navitus, federal timelines apply. These are standardized and give you predictable time frames for decisions and appeals. Customer Care can help you request an expedited review when a delay would seriously jeopardize your health, and they can provide the correct forms and addresses for written submissions.

• Part D coverage determination: standard within 72 hours; expedited within 24 hours.
• Part D redetermination (plan appeal): standard within 7 calendar days; expedited within 72 hours.
• Transition fills: within the first 90 days of plan enrollment, temporary fills may be available for drugs not yet meeting criteria, with written notice explaining next steps.

Specialty Medicines and Complex Care

If your therapy is a specialty medication handled through a specialty pharmacy, Navitus often coordinates with a specialty partner to manage cold-chain shipping, copay assistance, and clinical monitoring. In many Navitus-administered plans, the specialty partner is Lumicera Health Services, which provides pharmacist support, refill reminders, and side-effect management. Check your plan materials or medication label for the specialty pharmacy’s dedicated phone number.

Customer Care can confirm whether a drug must be dispensed by the specialty pharmacy, verify benefit coverage (medical vs. pharmacy benefit), and coordinate with your prescriber for prior authorization renewals. They can also advise on financial assistance programs from manufacturers or foundations when your out-of-pocket cost is high.

Privacy, Security, and Representation

Navitus enforces HIPAA privacy standards. Be prepared to verify your identity with your full name, date of birth, address, and Member ID before agents discuss protected health information. If you want a spouse, caregiver, or case manager to discuss your prescriptions on your behalf, ask Customer Care for a HIPAA authorization form and how to submit it securely. Powers of attorney and legal guardianship documents can also be placed on file.

For providers, Navitus will confirm NPI and practice details before discussing patient-specific benefit and clinical criteria. If you are a provider’s office, request the plan-specific PA form and include diagnosis codes, treatment history, and chart notes to avoid back-and-forth and shorten turnaround times.

Practical Tips to Speed Up Resolutions

Before calling, write down the exact drug name, strength, quantity, dosing directions, and the pharmacy’s phone number. If you received a rejection at the counter, ask the pharmacist for the reject code and message (for example, prior authorization required, refill too soon, or non-formulary). Having these details on hand often turns a multi-call problem into a single, successful call.

During the call, ask for a case or reference number and confirm the next action and timeframe (for example, “We will fax the PA form to Dr. Lee today; if not returned within 2 business days we’ll follow up”). If a promised action doesn’t occur, call back with the reference number for faster triage. For non-urgent issues, the secure member portal at navitus.com is a good alternative to phone queues and allows you to attach documents when needed.