I'm looking for a medication 

Network Health has a comprehensive list of covered drugs, which is also referred to as a Formulary or Preferred Drug List. This search contains the drugs Network Health covers under our plans. It includes the most commonly covered medications with information about drug tiers and any restrictions or special requirements. To find if a medication is covered, choose a Network Health plan type from the drop down below. Use Chrome for the best user experience. The formulary may change at any time. If you're a member and you're not already signed in, go to My Login to sign in to your member portal account for the most accurate results. 

About the Formulary

We may add or remove drugs from our formulary during the year. This includes changes to prior authorization requirements, step therapy, quantity limits and/or moving a drug to a higher cost-sharing tier.

What You Pay

When you find your drug, it will be listed with a tier number. The tier number for a drug determines what you pay for the drug, and the higher the tier, the more you pay. To find your pharmacy benefit costs for each tier, go to My Login and sign in to your member portal account (once signed in, go to My Benefits and then Pharmacy Benefits).

How Can I Request a Printed Formulary?

If you prefer a printed copy of your plan’s drug list, please call the customer service number listed on the back of your ID card. Alternatively, you may print the PDF located within the formulary search. 

Please note these lists change often, so make sure you have the most up-to-date version when searching for your drug. To use these lists, find your drug in the Index at the end. Then, scroll through the Index to find the page number for your medication and go to that page to find information about your medication.

Medicare Formulary Information

For additional information related to our Network Health Medicare Advantage Plans and the Medicare formulary, see the Medicare Formulary Information section under Medicare Plans, Pharmacy Information. The 2023 Medicare Formulary was last updated on August 1, 2023.

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 customer service 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 800-417-8164.  

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 customer service at the number listed on the back of your member ID card. 
  • The customer service 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.

State of Wisconsin Group Health Insurance Program

The following Network Health client companies do not use Network Health for processing their pharmacy benefits.

• State of Wisconsin Group Health Insurance Program

Employees of this company should check with their human resources department for more information about pharmacy benefits.