Provider Resources

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.

Medicare Pharmacy Information
Commercial Pharmacy Information

Pharmacy Network Update

On January 1, 2020, Network Health transitioned to Express Scripts, Inc® (ESI) as the pharmacy benefits manager for all lines of business. 

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

Formulary Overview

You will find our online formularies via the Look Up Medications tool. If you would like a printed copy of the formularies, you may print the PDF documents directly from the tool, or you can contact our pharmacy department to have a copy mailed to you.

Network Health manages commercial and Medicare formularies. ESI manages the exchange formulary. All formularies very similar with slight differences found within tier structures, drug tier placements, utilization management rules and other requirements or restrictions. Some of our utilization management strategies include prior authorization, step therapy protocols, quantity level limits and specialty drug restrictions. For commercial and Medicare, these rules are created and reviewed independently through our pharmacy and therapeutics committee and are administered through our pharmacy benefits manager, ESI. For exchange, these rules are created and reviewed through ESI's pharmacy and therapeutics committee and administered by ESI.

ESI administers prescription benefits for commercial, exchange and Medicare plans, including the review of our utilization management rules and maintaining the pharmacy network. ESI is the designated contact for all clinical medication reviews, exceptions and authorizations, regardless of the drug or pharmacy. In addition, ESI offers mail order services for all members.*

*Mail order for Network Health employee plan participants is handled through Ascension WI Retail Pharmacy Wausau.

Pharmacy Contact Information by Plan Type

Express Scripts, Inc. - Medicare

Prior Authorization Requests
CoverMyMeds 
ExpressPath 

Phone: 866-544-6962
Fax: 877-251-5896
Email: medicarepartdparequest@express-scripts.com

Express Scripts Customer Service
800-316-3107

Medicare Mail order prescriptions can be submitted to ESI by phone, fax or mail.
Phone: 888-468-5539 
Fax: 800-636-9494

Mail to:
ESI Mail Order
P.O. Box 66568
St. Louis, MO 63166-6568

Express Scripts, Inc. - Health Insurance Exchange

Prior Authorization Requests
CoverMyMeds 
ExpressPath 

Phone: 800-224-1062
Fax: 877-251-5896

Express Scripts Customer Service
800-340-1305

Mail order prescriptions can be sent to ESI by phone or fax.
Phone: 888-283-3858
Fax: 800-837-0959 

Express Scripts, Inc. - Commercial

Prior Authorization Requests
CoverMyMeds 
ExpressPath 

Phone: 800-209-0981
Fax: 877-251-5896

Express Scripts Customer Service
800-309-7583

Mail order prescriptions can be sent to ESI by phone or fax.
Phone: 888-283-3858
Fax: 800-837-0959 

Network Health Self-Insured

Ascension WI Retail Pharmacy Wausau 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.

Ascension WI Retail Pharmacy Wausau
Phone:  715-355-9573
Fax:       715-355-9579

Mail to:
1901 Westwood Center Blvd
Wausau, WI 54401

 

Prior Authorizations

ESI Care Continuum Prior Authorization Drug List for Medicare, Commercial and Health Insurance Exchange
Prior Authorization Drug List – January, 1, 2020
Prior Authorization Drug List – November 11, 2019
Prior Authorization Drug List – October 1, 2019
Prior Authorization Drug List – July 21, 2019
Prior Authorization Drug List – July 1, 2019
Prior Authorization Drug List – May 1, 2019
Prior Authorization Drug List – April 29, 2019

Authorization List for Step Therapy Drugs

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

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 ExpressPAth®
    • 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.  

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 customer service. 
    • The customer service representative can help the member request an exception to cover the drug.
    • When requesting an exception, a statement from the prescriber is often necessary to support the request for an exception. 
  • Examples of exceptions 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 for a coverage exception, 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 Health has partnered with ESI Care Continuum (CCUM) for medical drug prior authorization effective May 1, 2019. CCUM will handle pre-determination and prior authorization requests for medical drug (excluding oncology drug) for all lines of business, including Medicare, commercial and Health Insurance Exchange. eviCore will continue to review oncology medical drug requests.

Learn more about Care Continuum 

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

ESI Care Continuum Registration Portal User Guide
Video Portal Tutorials

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

Script Newsletter Archives

June 2019
January 2019

Informational Pieces

We've created informational pieces that you can share with your patients, if appropriate.
Statin Myths

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.