Pharmacy Information

Member Benefits

With a Network Health plan, our members receive access to pharmacy benefits and a number of online tools, such as Find a Pharmacy and Look Up Medications. Learn more about the pharmacy benefits members receive by reviewing the materials available to both commercial and Medicare members.

Individual Medicare Pharmacy Information
Group Medicare Pharmacy Information
Commercial Pharmacy Information
Individual and Family Pharmacy Information

Pharmacy Network Update

Express Scripts (ESI) is the pharmacy benefits manager for all Network Health lines of business. 

Provider Notification
Find important references and information to help you navigate our prescription drug plan formularies.

Formulary Overview

Froedtert Home Delivery must be used only for Network Health employee plan participants who use mail order prescription services. If the medication requires a prior authorization, contact ESI's prior authorization center to review the clinical criteria.

Prior Authorizations

Network Medical Drug Management (MDM) authorization services are submitted on the portal accessed on EviCore.com. Prior authorization request submissions for non-oncology specialty drugs for Network Health members will be submitted on EviCore.com.

Resources

Click here for an informational how-to document about the OnePA MDM Migration for Network Health.

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ESI Care Continuum Prior Authorization Drug List for Medicare, Commercial and Health Insurance Exchange
April 2025
May 2025

Care Continuum and Evicore Step Therapy Drug List
July 2024
January 2025
Medical Policies

To request a new or existing medication be added to the preferred drug list, please send a letter indicating the significant advantages of current preferred medications to the address below. Factors to consider include effectiveness, side effects, drug interactions and cost.

Network Health
ATTN: Pharmacy Benefits
1570 Midway Pl.
Menasha, WI 54952

Note: For Medicare, all prior authorizations for Part D oncology drugs and medical oncology drugs go through eviCore. For all other lines of business, prior authorizations for all pharmacy and medical oncology drugs go through eviCore.

Drug Exceptions

Network Health and ESI each have a Pharmacy and Therapeutics Committee that determines medication tiering and utilization management criteria based on clinical evidence, safety, cost and national recognized therapeutic guidelines. You can request an exception for a patient and request Network Health to cover a medication that is not covered or partially covered.

Exceptions can be handled both externally and internally. Exceptions usually require a supporting statement 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

• The patient can contact customer service for a list of similar drugs covered by Network Health. 
  • He or she can review this list with the prescriber and discuss alternate medication options. 
  • Network Health formulary drugs are often less expensive and easier to obtain than non-formulary drugs.
• The prescriber must obtain a prior authorization for the exception. This is necessary to determine medical necessity.
  • The 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 EviCore.com. 
  • If the prescriber is unable to submit the request electronically, this paper form can be faxed to Express Scripts. 
  • Contact Express Scripts at 800-417-8164 with any questions about this process.  

For Medicare, a decision will be made regarding the exception within three business days of receiving all the necessary information–including the supporting prescriber statement. You can request an expedited decision if you feel the patient's 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 the supporting prescriber statement.

• If a prior authorization is denied, the member can request an internal review by contacting Network Health. 
  • The customer service representative can help the member request to cover the drug.
  • When requesting, a statement from the prescriber is often necessary to support the request for an exception. 
• Examples include the below.
  • Request coverage for a drug, even if it is not on our drug list.
  • Ask us to remove coverage restrictions or limits on a drug.
  • If the internal review upholds the denial, the member will receive a written denial which will contain a form that he or she can complete and send back to request an external review by an independent review organization.

ESI Care Continuum (CCUM)

Network Medical Drug Management (MDM) authorization services are submitted on the portal accessed on EviCore.com. Prior authorization request submissions for non-oncology specialty drugs for Network Health members will be submitted on EviCore.com.

Resources

Click here for an informational how-to document about the OnePA MDM Migration for Network Health.

Learn more about Care Continuum 

Drug requests can be submitted via the EviCore.com, available 24 hours a day, seven days a week. Providers will have seamless access to EviCore.com through the Network Health provider portal. Providers should use their NPI number, not the facility NPI when submitting requests. 

• Network Health Wisconsin Provider Resources | EviCore by Evernorth

The Script

The Script is the bimonthly newsletter produced by the Network Health pharmacy department to inform providers of current and upcoming pharmacy-related news.

Statin Toolkit

We've created informational pieces that you may find helpful.

Statin Myths - Providers
Statin Myths - Member Handout - English
Statin Myths - Member Handout - Arabic
Statin Myths - Member Handout - Hmong
Statin Myths - Member Handout - Spanish


SUPD ICD-10 Exclusions

Safe Use of Opioid Pain Medication

The Center for Medicare and Medicaid Services (CMS) has published guidance to help prescribers and pharmacists diagnose opioid medications according to new Medicare drug policies.

Medicare Part D Opioid Policies: Information for Pharmacies

Medicare Part D Opioid Policies: Information for Prescribers

Medication Recalls

Oxbryta® Recall

On September 26, 2024 Pfizer voluntarily withdrew all lots of Oxbryta from the market. Read more about this recall.

Cinacalcet Recall

On October 9, 2024 Dr Reddy’s voluntarily recalled all lots of Cinacalcet 30 mg, 60 mg, and 90 mg tablets. Read more about this recall.