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Prior Authorization Process

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Yes. Navitus has identified a limited number of prescription drugs that require prior authorizations. Prior Authorization is initiated by the prescribing physician on behalf of the member. More information about which medications require prior authorizations, as well as the prior authorization process, is available to MN Advantage Health Plan participants and prescribers, on the Navitus Web site, www.navitus.com.

Certain drugs in the Navitus formulary are identified as requiring a "prior authorization" (PA).  This designation means that in order for a member to obtain the drug the member’s physician needs to submit documentation to Navitus that the member’s condition warrants dispensing the specific drug rather than the available alternatives. The required documentation is on the Navitus Web site prior authorization page. Navitus Customer Care can be accessed toll-free at 866-333-2757 is available to answer any questions you or your physician may have.

Navitus’ Pharmacy and Therapeutics (P&T) Committee creates guidelines to promote effective prescription drug use for each prior authorization drug. These guidelines are based on clinical evidence, prescriber opinion and FDA-approved labeling information. Some types of clinical evidence include findings of government agencies, medical associations, national commissions, peer reviewed journals, authoritative summaries and opinions of local experts.

  • Increase appropriate utilization of certain drugs
  • Promote treatment or step-therapy protocols 
  • Actively "risk manage" drugs with serious side effects 
  • Positively influence the process of managing drug costs


A provider must submit a Prior Authorization Form to Navitus via U.S. Mail or fax. The request will be processed as quickly as possible once all required information is gathered.

If the submitted form contains complete information, it will be compared to the criteria for use. A decision will be made within two business days.

If the submitted form lacks needed information, the provider will be contacted to provide the information. If the provider does not respond after seven calendar days, the member will be contacted by mail. The member has 45 calendar days to give Navitus the information. If the information is received within the 45 days, a decision will be made. If the information is not received by the end of the 45 days, the request will be denied.

A provider may notify Navitus by phone that an urgent request has been submitted. A decision will be made and the member and provider will be notified the same day the request is received. Urgent requests will be approved when:
  • A service delay could seriously jeopardize the member's life or health
  • A provider who knows the member’s medical condition says a service delay would cause the member severe pain that only the requested drug can manage
  • On weekends or holidays when a prescriber says immediate service is needed the pharmacy can give the member a four-day supply. The member is not responsible for the copay. During the next business day, the provider must submit a Prior Authorization Form.


ModeContact Information
Fax 1-920-735-5330


A prior authorization is required for specific drugs in order for coverage to apply. See the description above. If the prior authorization is denied by Navitus Health Solutions, meaning the situation does not meet the criteria for the drug to be covered, members then have the option to file an appeal.  

An appeal is a request to re-review the denial of coverage. A different person reviews the request from the original decision maker and makes a determination if the denial of coverage should be upheld or reversed.

In order to appeal a denial of coverage, it is helpful to have your physician send in clinical documentation that shows the appropriate criteria has been met.

Prior Authorization
Your physician submits the prior authorization to Navitus. See the description above.

Appeal
You or your physician can submit a letter requesting an appeal of a coverage determination.  The letter can be mailed or faxed to the Appeals Coordinator at Navitus Health Solution. When you have a question or concern about a benefit, claim or other aspect of service, we encourage you to call Navitus Customer Service toll-free at 866-333-2757. Navitus representatives strive to answer your questions and resolve your concerns promptly—your input allows Navitus to better meet your health care needs. To help the Navitus representative serve you more efficiently, please have your Navitus member ID card available when you call.

You have the option of paying for the drug yourself and, if the prior authorization and/or appeal are approved, Navitus would reimburse you for the cost of the drug if the drug was purchased within 30 days. 



About Navitus Health Solutions LLC
ID Card for Pharmacy Benefits
Which Medications are Covered?
Filling Prescriptions at a Pharmacy
Prior Authorization Process
Exception Processes
Coordination of Benefits
Contact Navitus
Complaints and Appeals
Definitions of Commonly Used Terms
 


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