Pharmacy

All you need to know

When you need medications, your provider and OhioHealthy Medical Plan want you to get the best available medication for your condition. Check out how we can help you manage your prescriptions and lower your costs. Depending on your plan, your pharmacy provider may differ. Refer to your member ID card for details.

Prescription Drug Formulary

View our list of covered drugs, which will help you and your provider choose the right drugs based on your needs.

Current Navitus Members can see their specific benefits by logging into their Navitus Member Portal. If you would like to see what drugs are included on our formulary or would like to price a medication, please click the link below and select your plan type. You do not need to be an active member to access these sites.

Note: this information is only relevant to you if the Navitus logo appears on your member ID card.

A doctor in a medical coat smiling at the camera.
Find a Pharmacy

You'll find the pharmacies you know and trust - local, independent and large national names as part of our nationwide network. Members: Once your benefit plan is in effect, please go to Member Login to access pharmacy information.

Navitus Pharmacy Network Listing

Prescription Drug Requests — Prior Authorizations, Exceptions & Appeals 

Navitus Health solutions processes prior authorization & appeal requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of OhioHealthy Medical Plan, To request prior authorization or an appeal for a drug that will be obtained under the PHARMACY benefit, submit the request to Navitus Health Solutions.  

Providers, members or authorized representatives can submit a request for drug coverage. 

  • Electronic requests: Submitting drug coverage requests online is convenient and allows your provider to track the status of the request. Your prescriber can log into our online portals to submit a drug coverage request electronically. 
  • Mail or Fax requests: Drug coverage request forms can be found below. These forms can be used to submit a request by mail or fax. 
  • Phone requests: Drug coverage requests can be initiated by phone. Call the applicable phone number listed to initiate a request. 

For fax or mail, use the forms below.

Prior authorization and appeal requests can be submitted by:

PHONE: (844) 268-9789 

FAX: (855) 668-8551 (toll free) 

MAIL: Navitus Health Solutions LLC 
Attn: Prior Authorizations 
1025 West Navitus Dr. 
Appleton, WI 54913 

How to make the most of your pharmacy benefit:  

  1. Download the Navitus app so you can discuss medication options with your healthcare provider on-the-go during your consultation. 
  2. Use the Navitus member portal Login (navitus.com) to research your pharmacy plan, cost of a medication at different pharmacies, see lower-cost alternatives and explore pricing for different dosage options. Learn how to use the member portal: Navitus Member Portal Demo Videos - YouTube 
  3. OhioHealthy has teamed up with Navitus and GoodRx, the largest discount card in the country, to provide you with even more savings. When you fill a prescription using the pharmacy benefit, at select pharmacies, Navitus will compare the out-of-pocket cost under your benefit to the GoodRx price. You pay whichever is less. Just present your OhioHealthy member card to start saving. It’s that simple! 
  4. Take advantage of our Copay Assistance Program. Many specialty medications have copay assistance programs, where a drug manufacturer pays for part of the drug’s cost in order to make it more affordable for patients. The Navitus Access team will help find options to lower your out-of-pocket costs for more than 400 specialty and HIV medications. Participation is required when available. If you fill a prescription for a specialty drug and use a manufacturer copay assistance program to reduce your out-of-pocket cost for the drug, only the actual amount you pay will count toward your deductible and out-of-pocket maximum 
  5. Fill your Specialty Medications through OhioHealth Pharmacies: OhioHealth Specialty Pharmacy located in Riverside Methodist Hospital is the preferred provider of specialty medications. Services include mail order pharmacy, local pickup, and prescription synchronization ensuring you get all of your medications – retail and specialty – at the same time.  
  6. Other Specialty Pharmacy Options. If the OhioHealth Specialty Pharmacy is unable to meet your needs for specialty medications, or you would like to use a different in-network pharmacy, your specialty medication will be sent to you by Lumicera 
  7. Know how your prescriber can begin the Prior Authorization process? 
    A. Non-Urgent Requests 
    A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. The request processes as quickly as possible once all required information is together. 
     
    If the submitted form contains complete information, it will be compared to the criteria for use. 
     
    If the submitted form does not have all of the needed information, the prescriber will be contacted to provide the information. If the prescriber does not respond within a designated time frame, the request will be denied. 
     
    B. Urgent Requests 
    A prescriber may notify Navitus by phone or fax of an urgent request submission. A decision will be made within 24 hours of receipt. The member and prescriber are notified as soon as the decision has been made. 

Good Information to know about your pharmacy benefit: 

A list of medications covered by your medical plan, organized into tiers – the higher the tier, the higher the cost of the medication. This list is updated quarterly. If you are prescribed a medication, check to see if it appears on this list; if not, discuss the possible alternatives with your healthcare provider to save money.

If you choose a brand name medication when a generic is available, you will pay the coinsurance, plus the cost difference between the two drugs (the difference does not count toward your deductible or out-of-pocket maximum). 

A medication that requires special handling, administration or monitoring — typically one used to treat complex conditions.  

For some medical conditions, there are drugs with similar clinical effectiveness but wide variation in price. You may need to try a ‘step 1’ medication before a ‘step 2’ medication is covered. 

Some medications require prior authorization before a prescription can be filled. Your doctor or your pharmacist will let you know if you need prior authorization. 

Some medications have quantity limits to promote the appropriate use of medications, prevent waste and help control costs. 

Some medications that are taken regularly or for an ongoing condition are called maintenance medications at any in-network retail pharmacy based on your benefit design. You have the option of filling a three-month supply of your maintenance medication at any in-network retail pharmacy. 

Drug manufacturers often issue coupons to encourage continued use of a more expensive brand name drug, even though less expensive similar or equivalent options have become available. Note that the coupon value is often counted toward your deductible, even though you are not paying that amount out-of-pocket. This may have tax reporting implications for you. 

Navitus will help you apply for coupons when available so you can take advantage of these savings. If you fill a prescription for a specialty drug and use a manufacturer copay assistance program to reduce your out-of-pocket cost for the drug, only the actual amount you pay will count toward your deductible and out-of-pocket maximum.