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Authorization Lists and Forms

Commercial Plans

Timelines for submitting requests and response times

2022 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
August 2022
September 2022

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.

2021 Prior Authorization Lists

General

Fillable Forms

Authorization Request Form

Copyright 2022 Network Health Plan, Network Health Insurance Corporation and Network Health Administrative Services, LLC. All rights reserved. HMO and POS plans underwritten by Network Health Plan. Self-insured plans administered by Network Health Administrative Services, LLC. Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Y0108_1850-03-0921_2022_F Last Updated Aug 11, 2022 9:23 AM

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