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Understanding Your Drug Coverage

Through our partnership with Express Scripts® (ESI), it's easier to get your prescriptions filled than it is to pronounce them.

Find a Pharmacy

Always use an in-network pharmacy so your prescriptions are covered by your plan. To find in-network pharmacies near you, use our Find a Pharmacy search. You can also go to My Login to access your account and find a pharmacy.

Pharmacy Tools

In addition, when you log into your account, go to My Benefits, then Pharmacy Benefits and you will be taken to the ESI portal, where you will find these helpful tools.

  • Understand My Plan and Benefits - Learn about your plan's benefits to help you save money. Compare the pricing and coverage differences between filling a medication at a participating local pharmacy and via mail service. You can also explore which brand-name drugs have generic alternatives available.
  • View Prescription History and Personalized Drug Information - View your prescription history and find information about your medications.
  • Ask-a-Pharmacist - Get confidential and reliable answers to your prescription and over-the-counter drug questions, 24 hours a day, seven days a week.
  • Refills On-the-Go - Set up and manage your prescriptions from anywhere, anytime. Download the free Express Scripts mobile app to refill prescriptions on the go.

Find Drug Costs

Network Health has a Preferred Drug List, which is also referred to as a Formulary. This list contains the drugs that Network Health covers under our health insurance plans. It includes covered medications with information about their tier and any restrictions or special requirements.

Use our Look Up Medications tool to search for covered drugs. You can also perform this search in your account by going to My Login for the most accurate information.

To learn the cost of your medication(s), before copayment or coinsurance, visit Express-Scripts.com/NetworkHealth. In addition to pricing information, you will find generic alternatives, if they're available, and medication FAQs.
*Please note, the price and tier information are not plan-specific and are estimates only. Your prescriptions may be more or less depending on your pharmacy or plan design.

Save Money with Mail Order

If you prefer to receive your medications in the mail, you can save time and money by signing up for home delivery. With this service, your prescriptions will be delivered right to your door.

Here’s how to sign-up.

  • Create an account at Express-Scripts.com or download the Express Scripts mobile app. Once your account is created, any prescriptions you have available for mail-order will be listed on your home page. 
  • Call ESI at the number listed on the back of your member ID card, 24 hours a day, seven days a week.
  • Or, go to My Login, sign in to your account and go to My Benefits, then Pharmacy Benefits. Select Plan Savings Opportunities on the right side of the page and click the Save with Mail Service Programs button.

Standard shipping is free and your prescriptions should arrive within 14 days of the date ESI receives your order.

SaveOnSp Program

Network Health partners with ESI to help members save money on eligibile specialty prescriptions. This program is available only for select Network Health plans that are made available to members/participants through their employer.

  • Assure plans
  • Fully insured large group plans (plans that have 50 or more enrollees)
  • Self-funded plans 

If you have any questions regarding what plan you have through your employer, contact your Human Resources department.

Program details

  • Receive eligible specialty medications free of charge ($0)
    • Certain specialty drugs that are considered non-essential health benefits are not subject to the out-of-pocket limits set under the Affordable Care Act
    • View the SaveOnSP Drug List
  • Prescriptions will be filled through your approved specialty pharmacy
  • If you do not participate in the SaveOnSP program, you will be responsible for the coinsurance noted for the medications on the SaveOnSP Drug list
  • These medications will not count towards your deductible or out-of-pocket maximums
If you have any questions or need more information, please contact SaveOnSP at 800-683-1074 Monday–Thursday from 7 a.m. to 8 p.m. and Friday 7 a.m. to 6 p.m.

Drug Exceptions and Member Responsibilities

Network Health's Pharmacy and Therapeutics Committee determines medication tiering and utilization management criteria based on clinical evidence, safety, cost and national recognized therapeutic guidelines. If your prescribed medication is not covered or partially covered, you or your prescriber can ask us to cover it. This is considered an exception.

Exceptions can be handled both externally and internally. Exceptions usually require a supporting statement from your prescriber explaining why alternative medications are not sufficient.

Common Exception Reasons

  • The requested drug is not on the formulary
  • The requested drug is part of a step therapy
  • A medical condition or drug interaction exists that may require use of the requested drug
  • The requested drug requires a prior authorization

How to Handle a Potential Exception

  • You can contact member experience at the number listed on the back of your member ID card for a list of similar drugs covered by Network Health. 
    • You can share this list with your prescriber and ask for a similar medication. 
    • Network Health formulary drugs are often less expensive and easier to obtain than non-formulary drugs.
  • Next, your prescriber must obtain a prior authorization for the exception. This is necessary to determine medical necessity.
    • Your prescriber can complete a prior authorization electronically or via fax and explain why an exception is required. 
    • Electronic requests can be done through portals such as CoverMyMeds® or ExpressPAth®. 
    • If the prescriber is unable to submit the request electronically, this paper form can be faxed to Express Scripts. 
    • If your prescriber has questions, he or she can call Express Scripts at 800-209-0981.  

A decision will be made regarding your exception within three business days of receiving all the necessary information–including the supporting prescriber statement. You can request an expedited decision if you or your doctor feel your health could be harmed by a three-day waiting period. If your expedited request is granted, a decision will be provided within 24 hours of receiving your doctor’s supporting statement.

  • If a prior authorization is denied, you can request an internal review by contacting member experience at the number listed on the back of your member ID card. 
    • The member experience representative can help you request an exception to cover your drug–he or she can direct you where to send the request.
    • When requesting an exception, a statement from your prescriber is often necessary to support the request for an exception. 
  • Examples of exceptions include the below.
    • You can ask us to cover your drug, even if it is not on our drug list.
    • You can ask us to remove coverage restrictions or limits on your drug.
    • If the internal review upholds the denial for a coverage exception, you will receive a written denial which will contain a form that you can complete and send back to request an external review by an independent review organization.

Prescription Drug Claim Form

If you purchased prescription drugs without presenting your ID card (due to an emergency or at non-participating pharmacy of medical facility), complete our prescription reimbursement claim form for consideration of reimbursement from ESI.

Diabetic Monitoring Devices

Network Health has partnered with OneTouch® to bring diabetic monitoring meters to our members at no cost. 

 

Medication Recalls

This section will contain information about manufacturer medication recalls.

A drug that’s discovered, developed and marketed by a pharmaceutical company. This drug is protected by a patent.

Generic drugs are received and approved by the Food and Drug Administration as having the same active ingredients as their brand name counterparts. That means they work the same as brand name drugs, but can cost up to 80 percent less than brand name drugs. You can save money by asking for generics first.

Like preventive care or services, preventive drugs can help you avoid many illnesses and conditions. As part of your Network Health plan, these drugs cost $0.

Sometimes also referred to as a Formulary or Preferred Drug List, this is a list of covered drugs that includes the most common medications with information about their tier and any restrictions that make exist.

The cost level of a drug. The higher the tier, the more you will pay.