Frequently Asked Questions

Medicare prescription drug plans are available to people with Medicare. Insurance companies and other private companies work with Medicare to offer these drug plans. They negotiate discounts on drug prices for plans and their members.

Medicare Prescription Drug Plans provide insurance coverage for prescription drugs. Like other insurance, if you join, you will pay a monthly premium and pay a share of the cost of your prescriptions. Costs will vary based on the drug plan you choose.

Drug plans may vary in which prescription drugs are covered, how much you have to pay, and which pharmacies you can use. All drug plans will have to provide at least a standard level of coverage, which Medicare will set. Some plans might offer more coverage and additional drugs for a higher monthly premium. When you join a drug plan, it is important to choose one that meets your prescription drug needs. 

Navitus MedicareRx (PDP) is a prescription drug plan that includes both Medicare Part D coverage and an employer-sponsored "wrap" plan. This wrap plan supplements the Medicare Part D coverage.

We do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. In general, we only cover drugs that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary.

Medicare beneficiaries with low or limited income and resources may qualify for extra assistance. If you qualify, your Medicare prescription drug plan costs will be less, the amount of your premium will be less and your drug costs at the pharmacy will be less. Once you have enrolled in Navitus MedicareRx (PDP), Medicare will notify Navitus as to how much assistance you are receiving currently. Then, we will send you information on the amount you will pay. If you do not receive assistance currently, but believe you should be, please contact Medicare to see if you might qualify. They can be reached at 800-MEDICARE (TTY/TDD users may call 877-486-2048, 24 hours a day/7 days a week).

Assistance is also offered through the State Health Insurance Assistance Program (SHIP). SHIP is a government program with trained counselors in every state. SHIP is not connected with any insurance company or health plan. It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. To find the contact information for a SHIP counselor in your state, use the Helpful Contacts tool located on the Medicare.gov website.

You can enroll during your employer’s open enrollment period. This enrollment will apply to the next year. Please check with your employer for more information about enrollment.

You will receive benefit information, as required by the Centers for Medicare and Medicaid Services (CMS). This information will include:

• ID Card
• Summary of Benefits
• Pharmacy Directory
• Formulary
• Evidence of Coverage (details about your pharmacy coverage)

Your formulary is a list of drugs covered as part of your pharmacy benefit. It is developed by medical and pharmacy experts. Formularies help to ensure that your health care professional selects medicines for you that are safe, effective and affordable.

The Navitus Pharmacy and Therapeutics (P&T) Committee first reviews medications for their therapeutic value, effectiveness and any side effects. Next the committee looks at the cost of the drugs. Formulary additions, exclusions and changes for drugs requiring prior authorization may be made under the direction of the P&T Committee. This committee meets quarterly. Therapeutic class reviews may also be carried out at each committee meeting. The entire formulary is reviewed at least once per year. This continual evaluation ensures the formulary is kept up-to-date and patient needs are met.

Yes. Navitus MedicareRx (PDP) uses a formulary. This formulary contains Medicare Part D drugs. It also contains most drugs covered by the plan’s supplemental coverage. However, some products are covered by the plan’s supplemental coverage that are not on the formulary.

Please refer to your formulary to determine if your prescription is covered under the Navitus MedicareRx (PDP) formulary. If your prescription is not listed, please contact Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. Pharmacies can reach Navitus MedicareRx (PDP) Customer Care 24 hours a day/ 7 days a week. 

Your formulary is provided with your new member materials. However, your formulary may change over time. Visit our member portal for the most up-to-date information.                                   

You can also call Navitus MedicareRx Customer Care toll-free at 866-270-3877. TTY users can dial 711. Customer Care can be reached 24 hours a day, 7 days a week, except Thanksgiving and Christmas Day.

This formulary contains Medicare Part D drugs and most drugs covered by the plan’s supplemental coverage, however, there are some products covered by the plan’s supplemental coverage that are not on the formulary. Please refer to your formulary to determine if your prescription is covered under the Navitus MedicareRx (PDP) formulary.

There is a process to help new members whose drugs are not on our formulary. You will be able to fill up to a 1 month supply of your drug. (If you are in a Long Term Care facility, you will receive up to a 31-day fill of your drug.) During this time, we suggest you contact us to see if we cover another drug used to treat your medical condition. If we do, we suggest you confer with your doctor to see if this alternative is an option for you.

Your doctor will give you a prescription if he or she believes the drug is medically-appropriate for treating your conditions. If the drug your doctor prescribes is not on the formulary, it is likely that your plan has similar drugs available.

If your doctor tells you that a drug or drugs on our formulary are not medically appropriate for treating your condition, you have the right to request an exception from us to cover your current prescription. If your prescription is not listed or to learn more about our exception process, please contact Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.

In the event that you lose your ID card, you will need a new card. You may request a new card by calling Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.

This formulary contains Medicare Part D drugs and most drugs covered by your plan’s supplemental coverage. However, there are some medications covered by your plan’s supplemental coverage that are not on  listed.  To determine if your prescription is covered, refer to the Navitus MedicareRx (PDP) formulary on the member portal for a complete list of medications under your supplemental coverage.

If you are a new member with a medication that is not on our formulary, you can get a one-month supply of your medication. If you are in a Long Term Care facility, you will  receive up to a 31-day fill of your medication. This will give you time to contact your prescriber to see if there are other alternatives that would be appropriate for you.

If your doctor tells you that a drug (s) on our formulary are not medically appropriate for treating your condition, you have the right to submit an exception request  to us to cover your current prescription.  To learn more about our exception process, contact Navitus MedicareRx (PDP) Customer Care toll-free at 866-270-3877. TTY users should dial 711. Customer Care is available   24 hours a day, 7 days a week, except Thanksgiving and Christmas Day.   

In most cases, you will be able to continue to use your current pharmacy. As a result of Navitus’ relationships with many pharmacies nationwide, you have many opportunities to locate a pharmacy right in your neighborhood. Listings of national and local pharmacies within the network are available through the MedicareRx Member Portal, www.medicarerx.navitus.com. Members may also contact Navitus MedicareRx (PDP) Customer Care to determine if a specific pharmacy is covered, or for more information about the Navitus pharmacy network.

Navitus MedicareRx (PDP) Customer Care can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.

If you are traveling and require the a prescription fill or refill, the following policy applies:

If traveling for less than one month:

• Any participating pharmacy can arrange for an additional one-month supply to be taken with you. A copay or coinsurance will apply to each month’s supply*;

        Or

• You can obtain a 90-day supply at pharmacies participating in the 90-day program;

        Or

• You can request that your participating pharmacy mail a one-month supply to you at the address where you will be staying.

If traveling for more than one month and within the United States:

• You can request the participating pharmacy located in the area where you will be traveling to have your current pharmacy transfer your prescription order;

        Or

• You can obtain a 90-day supply at pharmacies participating in the 90-day program. You must have obtained three 30-day fills prior to requesting a 90-day fill;

        Or

• You can request that your physician write an additional prescription order to be taken with you during your trip. This assumes that this prescription will be dispensed at a participating pharmacy located in the area where you will be traveling.

If traveling for more than one month outside the United States:

• Please contact Navitus MedicareRx (PDP) for information regarding the dispensing of covered drugs while out of the country.

*You may request an additional one-month vacation supply of your medication(s) by following these steps:

1. Contact Navitus MedicareRx (PDP) Customer Care at least one week prior to leaving for your vacation.
2. When requesting your refill from the pharmacy, explain that you have contacted Navitus MedicareRx (PDP) regarding obtaining an additional one-month vacation fill.
3. Obtain your medication(s) from the pharmacy prior to leaving for vacation.

Please contact Navitus MedicareRx (PDP) Customer Care if you need a vacation refill that extends into a the next benefit year.
 

Navitus MedicareRx (PDP) offers a Medication Therapy Management (MTM) program for members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. This program was developed for Navitus MedicareRx (PDP) by a team of clinicians. It is free for members that qualify.

We will send a program introduction letter to members who qualify. Qualifications are based on prescription drug history. The MTM program clinician will review members’ drug information. The MTM clinician may then call the member to talk about his or her health histories and medicines. Members are identified to receive calls based on a review of the member’s pharmacy claims. The member also has the option to call a program clinician to schedule a comprehensive medication review.
 
The program clinician ensures that members are using the appropriate drugs to treat their medical conditions. He or she will also identify possible medication errors. The program manager may also talk with the member about ways to save money on drugs and ways to better manage the member’s health, if applicable. The clinician will also share this information with the patient's physician as it relates to medicines that require a prescription. Members in the program may receive a phone call and/or written information on a regular basis, as determined by our review of members’ pharmacy claims.

In order to file a claim for reimbursement, you must provide specific information about the prescription in question, including information related to why reimbursement is being requested and payments that have been made by primary insurers. To file a claim, send all appropriate information with the receipt attached to Navitus MedicareRx (PDP) at the following address:

Navitus MedicareRx (PDP)
P.O. Box 1039
Appleton, WI 54912-1039

Copies of the Navitus MedicareRx (PDP) claim forms may be downloaded from the website. They may also be obtained by calling Navitus MedicareRx (PDP) Customer Care toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.

As a Medicare beneficiary, you have the right to file a grievance or an appeal if you are unhappy or dissatisfied with any of the benefits or services you are receiving.

What is a grievance?

Medicare denotes that a grievance is any complaint other than one that involves a request for an initial determination or appeal. Members may file a grievance for such issues as the behavior of a pharmacist or excessive wait times at the pharmacy.

If you wish to file a grievance with Navitus MedicareRx (PDP), you or your designated representative may call Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. You may also submit a grievance in written form.

If your complaint is received by telephone, we will address and resolve your complaint by telephone, especially if your complaint involves a possible misunderstanding or misinformation. If you request a written response, or if your concern is regarding a Quality of Care issue, we will respond in writing to you. The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension or if we justify a need for additional information and the delay is in your best interest.

If you choose to submit your grievance in writing, please send it to:

Navitus MedicareRx (PDP)
Attn: Grievance and Appeals
PO Box 1039
Appleton, WI 54912-1039

Or via Fax: 855-673-6507

What is an appeal?

You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for, or if you think we should have reimbursed you more than you received or you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny an exception request or you receive an adverse coverage determination, you can appeal.

You need to file your appeal within 60 calendar days from the date included on the specific notification, such as the notice of coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you or your designated representative may call Navitus MedicareRx (PDP) Customer Care toll-free at 866-270-3877 for an explanation on how to file an appeal. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. You may also send a signed written appeal to Navitus MedicareRx (PDP), PO Box 1039, Appleton, WI  54912-1039.

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you, or your doctor, or other prescriber to get more information. After we receive your appeal, we have up to seven calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.

You, your doctor, or your appointed representative can ask for a fast appeal (rather than a standard appeal) by calling Navitus MedicareRx (PDP) Customer Care. They can be reached toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas.You may deliver a written request to:

Navitus MedicareRx (PDP)
PO Box 1039
Appleton, WI 54912-1039.

You may also fax it to us at 855-673-6507 during or outside our regular business hours.

Be sure to ask for a “fast,” "expedited," or “72-hour” review. Remember that if your prescribing doctor provides a written or oral supporting statement explaining that you need the fast appeal process, we will automatically treat you as eligible for a fast appeal.

Please see your Evidence of Coverage for more detailed information concerning the grievance and appeal process.

Please contact Navitus MedicareRx (PDP) Customer Care toll-free at 866-270-3877. Or TTY users please call 711. Customer Care can be reached 24 hours a day/7 days a week, except Thanksgiving and Christmas. Pharmacies can reach Navitus MedicareRx (PDP) Customer Care 24 hours a day/ 7 days a week.

Navitus is committed to reducing fraud, waste and abuse. We take all inquiries seriously. If you have lost your ID card, believe your ID card was stolen, or have received notice of a prescription drug claim that you did not fill, please contact Navitus MedicareRx Customer Care. We can be reached at 866-270-3877. You can reach us 24 hours a day, 7 days a week, except Thanksgiving and Christmas Day. Read more about Fraud, Waste and Abuse.