For State employees:

A Pharmacy Benefit Manager (PBM) is a company that negotiates costs between drug manufacturers, pharmacies, and health care insurance providers.  They also process pharmacy claims and review Prior Authorizations.  

Navitus Health Solutions (Navitus) is the PBM for the state of Arkansas plan.  The Navitus customer care number is 844-384-2438.

A formulary is a list of medications that are covered or excluded by your health care plan.  Based on clinical evaluation and cost, these medications are categorized by Tiers.  The formulary will also list out any other information about medications such as if a Prior Authorization is required, if there are Quantity Limits, if a drug is Restricted to Diagnosis, etc.

Coverage and tier decisions are first made by a clinical team of pharmacists and doctors, and any changes to the formulary are then reviewed and approved by the Arkansas State Employee and Public School Employee Commissions, Board of Finance, and legislative committees.  

You may find the current formulary here.

Some covered medications require a Prior Authorization (PA) before the plan can determine payment.  Prior Authorizations may require office notes, lab values, or other clinical information from your provider.  

If a Prior Authorization is denied, your provider may appeal the decision by providing additional clinical information or scheduling a peer-to-peer conversation with Navitus.

A provider must file a Prior Authorization request with Navitus.

Non-covered medications are not paid for by the Plan formulary for various reasons such as cost or clinical effectiveness.  These medications are routinely reviewed by the Plan when new data and research are available and can possibly be added to the formulary.

Only members can file an appeal on a non-covered medication.

A member may submit the Appeal Form to the Employee Benefits Division (EBD). Determinations will be mailed to the member within 30 days of EBD’s receipt of the appeal.  Please note non-covered medications will not be approved unless all covered medications are tried and failed and there is no guarantee of approval.  

There are multiple medication classes designated as an excluded category.  Medications in these categories are excluded from coverage and do not have an exception or appeal option.  These exclusions were voted on by the Arkansas State Employee and Public School Employee Advisory Commissions, Board of Finance, and the Arkansas Legislative Council.  These categories include:

• Weight loss
• Hair growth
• Anti-wrinkle
• Over-the-counter (OTC) products
• Gender dysphoria
• Infertility
• Abortifacients

No.