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Authorization Lists and Forms

Commercial Plans

Timelines for submitting requests and response times

2021 Prior Authorization Lists

General

Commercial Membership (Fully Insured)
Individual and Family Plans and Small Group ACA
Health Insurance Exchange
State of Wisconsin (ETF)
Self-Insured Assure Plans
Self-Insured Horizon and Network Health

Pharmacy

ESI Care Continuum Prior Authorization Drug List

September 2021

October 2021

Prior Authorization Drug List 
Authorization List for Step Therapy Drugs

Genetic Testing

Genetic Testing Authorization Resources

Experimental or Investigative

For the most up-to-date Experimental and Investigational Authorization List,
please contact us at 800-826-0940, Monday, Wednesday, Thursday and
Friday from 8 a.m. to 5 p.m., and Tuesdays from 8 a.m. to 4 p.m.

2020 Prior Authorization Lists

General

Commercial Membership (Fully Insured)
Individual and Family Plans and Small Group ACA
Health Insurance Exchange
State of Wisconsin (ETF)
Self-Insured Assure Plans
Self-Insured Horizon and Network Health

 

 


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.