Complaints

This profile includes complaints for Navitus Health Solutions's headquarters and its corporate-owned locations. To view all corporate locations, see Find Local Branches.

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  Navitus Health Solutions

  361 Integrity Dr Madison, WI 53717-1416

• 

  Navitus Health Solutions

  2601 W Beltline Hwy Ste 600 Madison, WI 53713-2327

• 

  Navitus Health Solutions

  1025 W Navitus Dr Appleton, WI 54913-9017

The complaint text that is displayed might not represent all complaints filed with BBB. 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.

• Initial Complaint

  Date:06/23/2025

  Type:Service or Repair Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Over the past 6 months, since my insurance company switched to using Navitus for its prescriptions, they have tried to force me to change 4 different medications. 3 of which I have been on for years through this same insurance. They are telling me to switch to a medicine I am allergic to, or pay $50 more per prescription. After being told that the issue was solved and I would get the lower copay for 1 full year, they switched it back to $50 more within 4 months. Now theyre claiming it never shouldve been lowered. Theyve also denied coverage for migraine medication, suggested insulin that is not appropriate for my insulin pump, raised my copay price for anti-depressants by 700% and restricted my diabetes supplies.

  Business Response

  Date: 07/01/2025

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

  Customer Answer

  Date: 07/01/2025

  [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

  Date:06/06/2025

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  My medication which is for an autoimmune disease was transferred to Lumicera which is wholly owned by *******. They have been a complete nightmare to work with. Their staff is rude. They will not dispense my medication for weeks after I was supposed to take it. This will result in a dramatic quality of life for myself. The resolution I am seeking is to get my medication so I can work.

  Business Response

  Date: 06/10/2025

  We have attached our response letter to the patients recent BBB complaint. Thank You!

• Initial Complaint

  Date:05/08/2025

  Type:Order Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Navitus is responsible for payment of prescription claims for the city and county of *************. They were hired to pay claims as of January 1, 2025. They have either not paid claims or have paid some claims. There performance has been spotty at best. This non-payment is impacting our business.

  Business Response

  Date: 05/19/2025

  We have investigated the complaint and provided the attached response. 

• Initial Complaint

  Date:02/25/2025

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I have contacted Navitus several times within the last 2 weeks about my prescriptions that are being rejected in February, causing me to have to pay cash price at the pharmacy when these same prescriptions cost $5.00 ( per our family coverage policy contract) when I had them filled at the same pharmacy in January (last month). My most recent phone call was yesterday when I spoke with ****** in ***************** The phone call lasted well over an hour with no resolution being offered before hanging up. ****** told me she would need to contact the pharmacy today and get back with me with resolution after she got reasons for rejections from the pharmacist on duty. She advised me to hold off on picking up any filled prescriptions from the pharmacy to avoid complicating things further. She also advised me to wait for a resolution before i filed reimbursement claims with Navitus for any prescriptions I picked up 2 weeks prior to yesterday's phone call at which time i had to pay full price for those prescriptions. My first phone call to Navitus regarding this issue was made shortly after returning home that evening, I was told then that the issue was due to the prescriptions expiration date even though the prescribing doctor just recently sent new prescriptions to the pharmacy electronically in December 2024 so expiration date could not possibly be the reason for these prescriptions being rejected by Navitus. I have not received any calls from anyone from Navitus to provide an explanation or offer a resolution to this problem. The medicines are blood *********************** maintenance drugs (to name a few) that should not be stopped immediately without consulting the prescribing physician so therefore I must pay the higher price for them until this issue is resolved but no one seems to have any idea what is even causing the problem to begin with. Neither of my family members on this policy has seen this huge price increase. I need Navitus to resolve this issue.

  Business Response

  Date: 02/27/2025

  Attached is Navitus Health Solutions response regarding the most recent BBB Complaint. 

• Initial Complaint

  Date:11/27/2024

  Type:Order Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  This company is extremely unethical! My mother has been using the dexcom device for years to measure her levels for diabetes and now Navitus won't prescribe her the device and forcefully wants her to order insulin and take insulin every week! The doctor does not recommend insulin but this company will not allow her to get the dexcom device without the insulin. Shameful! Although we pay for insurance for this specific reason...now it's gotta be out of pocket for dexcom. Thanks Navitus! This is why society is losing trust of these corporations.

  Business Response

  Date: 12/03/2024

  Dexcom G6 is covered under the members plan but requires step therapy if using insulin. If insulin is not being used, then an exception must be submitted by the members provider to our ******************************* ****** ********* previously had a one-year approval from back in 2023 that has since termed. Our records show two requests for continuation of coverage have been faxed to the provider on 11/25/2024 and 11/27/2024. These requests have not yet been returned by the provider. Our ****************************** will process these requests in a timely manner once the provider completes and submits them back to us.

• Initial Complaint

  Date:11/08/2024

  Type:Order Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  My son had an urgent need for a medication as prescribed by his doctors at Stanford Medicine Children's Health. The medication, ******* 200mg, 42 tablets, was partially filled at in-network pharmacies (34 of 42 tablets). When I attempted to fill the remaining 8 tablets, there was only one pharmacy in the State of California that had any in stock.I contacted the out of network Pharmacy (*********), and they informed me Navitus Health Solutions refused to pay for the medication. I immediately called Navitus Health Solutions, ************, and asked what was possible. The representation directed me to their Prescription Drug Claim ****, Direct Member Reimbursement. She told me Navitus would reimburse the entire cost, despite being out network, and for me to indicate the medication was related to a medical emergency (urgent/emergency) need. I spent a lot of time filling out the very detailed reimbursement form and mailed it in. Today I called the company and the first rep (after 20 minutes of talking), hung up on me. The second representation seemed helpful, but at the end, said no reimbursement would ever be made.I made this expenditure, only at the directing of Navitus, and the promise of paymnet. Navitus is in breach of their contract with *****************.

  Business Response

  Date: 11/14/2024

  Member filled a medication for their son at a pharmacy that was out of network and paid out of pocket. Member submitted a request for reimbursement which has been reprocessed by our Claims team. The check will be mailed to the member on 11/15/2024. 

  Customer Answer

  Date: 11/14/2024

  [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

  Date:11/01/2024

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I am writing to formally express my dissatisfaction and frustration with the handling of my recent health insurance inquiry and coverage. On October 29, 2024, prior to being discharged from the hospital, I was informed of my diagnosis of type 2 diabetes with an A1c level of 11.5. Given the severity of my condition, I reached out to Cigna on the same day to confirm if the Freestyle Libre, a critical tool for managing my blood glucose levels, was covered under my plan. I was assured by a representative that it was fully covered.Following this assurance, I visited my doctor on October 30, 2024, to obtain the necessary prescription for the Freestyle Libre. The prescription was sent to ********* in ******, **. When I went to pick up the device, ********* informed me that it was not covered. I called ***** again to clarify, and after some back-and-forth, ***** representatives contacted ********* to verify that the device should indeed be covered.After several more calls to Cigna, I was informed that my pharmacy benefits provider was, in fact, Navitusnot Cigna. Upon contacting Navitus, I was told that the Freestyle Libre is only fully covered for insulin-dependent patients. However, the representative mentioned that a waiver could be applied to ensure coverage in my case. I was told that Navitus would fax the required forms to my doctors office for completion. After following up with my doctors office, I found they had never received the forms. I called Navitus again and spoke to the same manager, who confirmed she would send them immediately. My doctor subsequently completed and returned the forms, yet my claim was denied.

  Business Response

  Date: 11/07/2024

  Based upon our review of this case, *** products are covered under members plan benefit with an approved prior authorization. There is a Step Therapy criterion that requires prior authorization approval concerning the utilization of insulin.

  Customer Answer

  Date: 11/07/2024

  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 request a third-party review of my situation. I am dealing with obesity, a recent diabetes diagnosis, and recurring cellulitis infections in my leg. I understand the need for prior authorization and your insistence on insulin use, but it should not have to escalate to that point before I can receive coverage for a Continuous Glucose Monitor (***). This device would help me manage my diabetes more effectively and prevent further complications, ultimately improving my overall health. The *** would be more cost-effective than both ********* and *********, medications you already cover. Given my condition, I should not be required to manually test my blood sugar multiple times a day, especially when I'm at risk for infections. The ***, which lasts 14 days, is a safer and more practical option.

   
  
  Regards,
  
  ******* ******* Jr.

  Business Response

  Date: 11/11/2024

  On 11/07/2024, the member asked for a third-party external review concerning the denial of coverage for Freestyle Libre 2 Kit. This request was submitted to an independent, external third-party for review on 11/07/2024 as requested. On 11/08/2024, the external third-party upheld he denial for coverage of Freestyle Libre 2 Kit. At this time, all levels of appeal have been exhausted.

• Initial Complaint

  Date:10/09/2024

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I filed a claim via online fax after paying cash for medications. I have not heard back for over a month, so I called. It was clear they were very lost and did not even realize I filed a claim. The agent, then, scrambled to review my claim and said they were not covered, except one medication. I asked for Navitus to send me a letter of denial or some sort of letter stating medications are not covered. Agent argued that they don't provide such letter, which is not true since I've submitted same claims dating back 2 years and I have always received a letter. She said they will send a letter. Regarding one medication they do cover, they send a letter saying the my price should have been less than $4.2 weeks pass and I still have not received a denial letter. I call back and speak to another agent. He said explanation of benefit will be sent. When I asked about the medication that is covered, he said the pharmacy already filed a claim on 8/2. This surprised me since I have not supplied the pharmacy with my insurance information. I have always paid cash and filed claim myself for 2 years. I knew the agent was misinformed.I called the pharmacy. They confirmed they never submitted a claim. I call Navitus back. Now the diffilerent agent is claiming that pharmacy filed a claim on 9/16, which is the same day I filed a claim. They basically thought my form was from the pharmacy and sent the check to the pharmacy, but the agent is adamant that they did not make a mistake. He is adamant that pharmacy filed a claim. From the experiences with navitus so far, I get different responses every time I call. The system and agents are very incompetent based by the fact that they give me different dates and wrong information every time I call. It is very frustrating and disappointing.

  Business Response

  Date: 10/16/2024

  This letter is in response to the BBB complaint filed on 10/09/2024 concerning an issue with manually filed claims based on the members cash payment at the pharmacy. 
  
  Claims for four drugs were submitted to Navitus by the member. Three of the drugs are not covered under the members pharmacy benefit and therefore there is no coverage available to issue a denial. The members plan through Self Insured Schools of ********** (****)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.  Certain categories of drugs are not covered under the **** benefit three of the drugs fall under a non-covered category.
  
  For the fourth drug, we can confirm that Navitus received the request on 09/16/2024. The billed amount for this medication by the pharmacy was $91.26, and the contracted reimbursement rate had this been paid to the pharmacy $3.75. The balance has been applied to the members plan out of pocket accordingly. No further reimbursement is due to the member.
  
  We hope this clarifies the process and information we reviewed for the members expressed concern. We trust that this explains the reasons for coverage and thank you for the opportunity to share this explanation and for bringing this to our attention. It allows us to track and trend issues and make improvements to our processes. Our goal is to always provide the best possible service to our members.
  
  If you have any questions about your pharmacy benefit, please call Navitus ************** You can reach them toll-free at **************.
  
  Sincerely,
  
  Grievance and ******************

• Initial Complaint

  Date:04/25/2024

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  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

  Date: 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

  Date:04/06/2024

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  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

  Date: 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.