Pharmacy Information

Our Plans

Network Health offers several Medicare Advantage Plans that include comprehensive medical and drug coverage. The following plans include built-in pharmacy coverage.

Network Health Select (PPO)
Network Health Choice (PPO)
Network Health PlusRx (PPO)
Network Health PremierRx (PPO)
Network Health Go (PPO)
Network Health Anywhere (PPO)
Network Health Zero (PPO)
Network Health Cares (PPO SNP)

Compare Drug Costs
Look Up Medications 
Find a Pharmacy

Important Reminders

• You can only be enrolled in one Part D prescription drug plan at a time. If you are enrolled in a Medicare Advantage Part D plan, you must receive the Part D coverage through that plan.

• If you do not add prescription drug coverage when you are first eligible (and you do not have coverage that’s as good as or better than Medicare Part D coverage) and you choose to add it later, you will have to pay a penalty.

• If you enroll in a Stand-Alone Prescription Drug Plan, you will automatically be disenrolled from the Medicare Advantage (PPO) or (HMO) plan and returned to Original Medicare.

• If you have Veterans Affairs (VA) benefits, you may be eligible for prescription drug coverage through the VA.

Important Message About What You Pay for Vaccines - Our plan covers adult, Advisory Committee on Immunization Practices (ACIP)-recommended Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Member Experience for more information. Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

Medication Programs and Extras

Medication Therapy Management

If you take several medications, we have a program to help you manage your medications and make them work the best for you.

Understanding Statins
You should feel confident in your prescription drug use, this information will help you understand the science behind statin use. Knowing the truth will help clear the confusion caused by common myths.

Medication Adherence

Following your treatment plan can help you stay healthy and symptom-free, and taking your medications as directed is particularly important. This resource can help you with that.

Part B Step Therapy Drugs

Certain Part B medications require you try a different medication before you can fill a prescription for it. This is called step therapy. Please reference this list to determine if your Part B medication is a step therapy medication.

Diabetic Monitoring Devices

Network Health has partnered with OneTouch^® and FreeStyle to bring diabetic monitoring meters to our members at no cost. To print off a voucher for a OneTouch meter at no cost, click on the OneTouch link above. To obtain a FreeStyle meter at no cost, call the manufacturer, Abbott, at 866-740-8343.

This document explains the Network Health policy for coverage of Continuous Glucose Monitoring (CGM) devices and supplies.

Medication Prescription Payment Plan

The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option may help you manage your expenses, but it doesn't save you money or lower your drug costs.

Long-Term Medication Supply 

Most Network Health Medicare members, can get a long-term supply (up to 100 days for Tier 1 or up to 90 days for Tiers 2-4) of drugs shipped to your home using our plan’s network mail-order delivery program. Refer to Chapter 5 in your Evidence of Coverage to determine if this benefit is available for you. Usually, you will receive your mail-order prescriptions within 14 calendar days. If your order does not arrive within the estimated timeframe, call Express Scripts Customer Service at 800-316-3107 (TTY 800-899-2114), 24 hours a day, seven days a week. If you are a new member with Network Health or new to using mail-order, Medicare requires that you provide consent for the first fill of a prescription. Express Scripts will contact you to obtain your consent. As a new mail order user, please allow 21 calendar days for processing and shipping of your prescription.

Extra Help

This Extra Help table shows what your premium will be if you get extra help from Medicare to pay for your prescription drug costs. 

Programs to Ensure Safe and Effective Use of Medications

Network Health uses procedures and software to ensure the most cost-effective and safe medication therapy is shared with our members. 

Safe Use of Opioid Pain Medication

This document explains the new policies put in place by the Centers for Medicare and Medicaid Services (CMS) to help members use opioid medications more safely. 

Medicare Formulary Information

Changes to the Formulary

We may add or remove drugs from our formulary during the year. In certain situations, if we remove drugs, add prior authorization, quantity limits and/or step therapy restrictions on a drug or, for members with a tiered formulary, move a drug to a higher cost-sharing tier, we must notify members who take the drug of the change at least 60 days before the change becomes effective (or when a member requests a refill). For changes made to the formulary due to a new generic or biosimilar becoming available for a brand name drug or original biological product, drugs removed from the formulary for safety reasons or because the drug is being removed from the market, a 60-day notice is not required. We will notify members no later than 30 days after those types of formulary changes are made.

Closed Formulary Negative Changes

Medicare Exceptions to the Formulary

You may ask Network Health Medicare Advantage Plans to make an exception to our prescription drug restrictions. To do so, you should submit a statement from your physician supporting your request. You or your provider can call us to ask for an exception, submit your request by using the link below or fax or mail the form found at the link below. 

Submit a Request for a Drug Coverage Determination

Medicare Pharmacy Information

What's an in-network pharmacy?

An in-network pharmacy is a pharmacy we have an agreement with to provide prescription drug coverage. To have your prescription drugs covered, you must use an in-network pharmacy. You may change your pharmacy at any time, as long as it's in our network. For help finding an in-network pharmacy, call the member experience number on the back of your Network Health ID card. You can also use our Find a Pharmacy search. The pharmacy network may change at any time, and not all in-network pharmacies may be listed. You will receive notice of changes when necessary. 

What's a preferred pharmacy?

An in-network pharmacy where drugs are covered at a lower cost.

What's a standard or non-preferred pharmacy?

An in-network pharmacy where drugs are covered, but at a higher cost.

When can I use an out-of-network pharmacy?

Under limited circumstances, we will fill prescriptions at out-of-network pharmacies. However, these occurrences should be rare. Our network of pharmacies extends nationally, so you can continue to get prescriptions filled outside of our service area. The types of pharmacies included in our network include retail, mail order, long-term care, Indian Health Service/Tribal/Urban Indian Health Program and home infusion pharmacies.

How can I request a printed pharmacy directory?

To request a printed pharmacy directory, call the member experience number on the back of your Network Health ID card. (Printed directories are only as current as the date indicated on the directory. For the most up-to-date information, the online search tool is the best resource.)

Forms and Policies

Express Scripts Pharmacy Mail Order Form

Sign up for convenient home delivery of your prescriptions with this mail order form. Or call 800-316-3107, 24 hours a day, seven days a week. Automatic refills are also available with mail order. If you choose not to use automatic refills, please contact your pharmacy 21 days before your prescription is due to run out, to ensure your mail order medications arrive on time. If you are a new member with Network Health or new to using mail-order, Medicare requires that you provide consent for the first fill of a prescription. Express Scripts will contact you to obtain your consent.

Prescription Drug Claim Form

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

Redetermination Request Form

Members have the right to ask us to reconsider a coverage decision made for a particular prescription drug.

Prescription Drug Coverage and Your Rights

Members have the right to request a coverage determination from your plan if you disagree with information provided by the pharmacy. This can also be done using the Express Scripts online form.

Transition Plan Policy

Our transition plan policy defines how Network Health provides a transition fill process for Medicare Part D beneficiaries.

CMS Best Available Evidence Policy

This is a Federal policy designed to ensure the Medicare Advantage plan has established appropriate cost-sharing for low-income beneficiaries.

Key Terms to Know

What's a drug tier?

For members with a tiered formulary, a drug tier is the cost category a drug belongs to. It determines what you pay for the drug, and usually the higher the tier the more you pay. For most tiers, if you have a benefit with preferred and standard pharmacies, you pay less when you use a preferred pharmacy. You can look up medications to find out what tier they are on in our Look Up Medications search.

What's a copayment?

A copayment is the set fee you pay for a prescription drug. For members with a tiered formulary, copayments vary based on the drug tier. If your benefit has preferred and standard (or non-preferred) pharmacies, you pay less when you use a preferred pharmacy.

Most of our plans have five drug tiers

 

What's the difference between brand name and generic drugs?

A brand-name drug or original biological product is a drug that is protected by a patent. The drug can only be made or sold by the company that holds the patent. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredients as a brand-name drug, but generally, the generic drug will cost less. Original biological products are more complex than typical drugs. Instead of having a generic form, they have alternatives called biosimilars.

Is a generic drug as good as a brand-name drug?

Yes, generic and biosimilar drugs are just as good as the brand name or original biological product because they are approved by the FDA as meeting the same standards.

How does the Medicare Part D Benefit work?

Medicare Part D, or prescription drug coverage, has three different stages of coverage.

1. Deductible

2. Initial Coverage

3. Catastrophic Coverage

The deductible stage is the first payment stage of drug coverage. During the deductible stage you will pay the full cost for drugs that apply to the deductible. The deductible does not apply to covered insulin products and most adult Part D vaccines. Once you meet your yearly deductible amount, you leave the deductible stage and move to the initial coverage stage.

During the initial coverage stage, we pay our share of the cost for covered prescription drugs and you pay your share (your copayment or coinsurance amount). You stay in the initial coverage stage until your total out-of-pocket costs reach $2,000. You then move on to the catastrophic coverage stage.

During the catastrophic coverage stage, you pay nothing for your covered Part D drugs.

The graphic below is an example of how the Medicare Part D prescription drug benefit works for 2025. The information below is based on the Medicare Part D standard benefit. Depending on your plan, your costs may be different.

Medication Recalls

This section will contain information about manufacturer medication recalls.