Navitus Health Solutions is dedicated to reshaping pharmacy benefit management with a focus on people-centered and cost-effective solutions. By partnering with health plans, employer groups, government programs, and other key segments, Navitus aims to improve lives by making medications more affordable. This article delves into Navitus' approach to medication coverage, with a particular focus on weight loss drugs and related trends.
Navitus: Redefining Pharmacy Benefits
Navitus distinguishes itself through its commitment to transparency and managing to the lowest net cost, benefiting both plan sponsors and members. Unlike traditional Pharmacy Benefit Managers (PBMs), Navitus passes along complete savings to clients, ensuring medication affordability. This approach has led to significant financial savings for its partners.
Real-World Impact
Clients have lauded Navitus for making their jobs easier, ensuring smooth formulary changes, and exceeding anticipated financial savings. The flexibility to craft customized programs that meet the specific needs of team members is a key benefit, enhancing their quality of life while saving money.
Pharmacy Benefit Trends and Navitus' Response
The pharmacy benefit landscape is rapidly evolving, with climbing drug prices, new federal policies, and the emergence of high-cost specialty therapies. Navitus helps manage prescriptions and lower costs through various strategies, including a nationwide network of pharmacies.
Formulary and Cost Management Tools
Navitus provides tools for members to research their pharmacy plans, compare medication costs at different pharmacies, and explore lower-cost alternatives. The Navitus Access team helps identify options to lower out-of-pocket costs for specialty and HIV medications, including participation in copay assistance programs.
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Prior Authorization and Appeals
Navitus processes prior authorization and appeal requests for drugs obtained under the pharmacy benefit. Electronic submissions are preferred for their convenience and tracking capabilities. Urgent requests are addressed within 24 hours to ensure timely access to medications.
Drug Trend Report: Key Findings
Navitus' annual Drug Trend Report offers insights into prescription costs and savings. The 2025 report highlighted how commercial plan sponsors saved millions while maintaining high-quality member care.
Cost Savings and Management
In 2024, 30% of Navitus clients spent less than in the previous year, with an overall drug cost trend managed to 7%. This is notable considering that industry-wide prescription drug spending increased by 11.4%. Navitus' commitment to transparency and managing to the lowest net cost has significantly benefited clients.
GLP-1 Receptor Agonists (GLP-1 RAs)
The report noted a 26% increase in GLP-1 RA use for treating type 2 diabetes. However, due to varying coverage decisions by clients, GLP-1s for weight loss were not included in the Drug Trend Report. The growing utilization of GLP-1 RA medications represents both an opportunity and a challenge for healthcare payers and providers. These medications, recognized as first-line therapies for T2DM by the American Diabetes Association, are also among the costliest therapies, with monthly drug costs ranging from $726 to $1,022 per patient.
Biosimilars and Specialty Medications
Biosimilars delivered $315 million in savings, with a 60% reduction in Humira costs. Specialty medication utilization increased by 12%, with approximately 75% of new drug approvals being for specialty or medical specialty agents.
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Methodology
The Navitus drug trend is calculated by comparing the net total cost per-member per-month (PMPM) for the specified year to that of the previous year. Net cost PMPM represents full-year data for total member copays and plan paid amounts minus manufacturer rebates and fees.
Managing GLP-1 RA Utilization
Navitus has implemented innovative strategies to manage the utilization of GLP-1 RAs, particularly in light of their increasing use for weight loss, which is often not covered by payers.
Automated Diagnosis Verification
To address the challenges of traditional prior authorization processes, Navitus employs an automated point-of-sale diagnosis verification system. This system requires proof of a covered medical diagnosis at the point of sale, automating diagnosis verification through an innovative claim adjudication system design.
Study Results
A study analyzing pharmacy claims data from 297,514 members demonstrated that requiring diagnosis codes at the point of sale effectively controlled both utilization and costs while maintaining appropriate access to medication. The intervention group saw a minimal increase in utilization (1.36% to 1.45%) compared to the control group (4.11% to 6.80%), with corresponding containment of per-member-per-month costs (PMPM) (15% vs 79% increase). Among claims initially rejected due to missing diagnosis codes, 78% were resolved within one day, suggesting this approach successfully balances cost control with timely access to medication.
Benefits for Stakeholders
This automated diagnosis verification creates value for all stakeholders in the healthcare system. Health plans and employer plan sponsors benefit from significant cost containment through utilization management with potential reduced administrative costs, compared to a traditional method. For pharmacies and healthcare providers, the streamlined workflow represents a significant improvement over the traditional utilization management methods, such as prior authorization. The requirements are clear for diagnosis code entry, and approval feedback is immediate, allowing for quick resolution of any issues. Patients benefit from faster access to appropriately prescribed medications.
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Limitations
The study design did not account for baseline differences between the intervention and control groups that may have affected GLP-1 RA utilization. Important variables that could impact outcomes include region-specific prescribing patterns, prevalence of diabetes, prevalence of obesity and socioeconomic status. The relatively short duration of 12 months provides limited insight into the long-term effects of the diagnosis code requirement. Direct comparisons to prior authorization outcomes were not part of the study design.
Trends in GLP-1 Drug Spending and Coverage
Navitus' commercial clients saw a 6.8% increase in their prescription drug trend in a specified year, according to the company’s Drug Trend Report. One of the largest impacts on drug spend is the growth of use in anti-glucagon-like peptide-1 (GLP-1) drugs to treat patients with diabetes. For Navitus clients, the trend for GLP-1 drugs increased 1.7% in the specified year even though less than 3% of members used these medications.
Increased Use and Sales
Sales of GLP-1 therapies have grown significantly, driven by drugs like Novo Nordisk’s Ozempic (semaglutide) and Lilly’s Mounjaro (tirzepatide). Increased attention has been on the GLP-1 class of medications after semaglutide was approved as Wegovy and tirzepatide as Zepbound to treat obesity.
Coverage Discussions
There are increased discussions about how to cover the GLP-1 therapies, especially in light of the added benefit they may have for some patients. As more data becomes available about how GLP-1 therapies impact the metabolic system, demand and use is expected to grow.
Impact of Biosimilars on Specialty Drug Spending
Within specialty drug spending, Navitus clients saw an overall cost trend of 5.7%. However, the launch of biosimilar products for Humira (adalimumab) reduced drug spend for clients in the specified year. Navitus expects client savings to increase because it expects to shift more patients to biosimilars. In a specified year, the branded Humira was removed from Navitus’ formulary.
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