Provider Resources

November 2019

Table of Contents

2020 Prior Authorization Requirements
2020 Annual Pharmacy Notification
2020 Benefits Training and FAQs
Save the Date for December Practice Manager Meetings
Network Health Organizational Changes to Better Serve You
Network Health Holidays
Check Run Calendar

2020 Prior Authorization Requirements

Network Health is making changes and removing some commercial and Medicare prior authorization requirements for 2020. Our population health management team is focused on ensuring Network Health members receive the right care, at the right place and at the right time. Our goal is to maximize health plan value for our members by delivering the highest quality services at the lowest cost with the least disruption to our members’ daily lives. Effective January 1, 2020, Network Health will be removing prior authorization requirements for several services, including the following.

  • Home ventilators
  • Hearing aids
  • Cochlear implants
  • INR devices
  • Continuous glucose monitors
  • Insulin infusion pumps

In addition, Network Health has increased the authorization threshold to $5,000 for prosthetic prior authorization reviews.

Network Health has also removed the potentially experimental/investigational/unproven status around skin substitute products. However, note that skin substitute services and select wheelchair accessories continue to require prior authorization with all commercial plans, and effective January 1, 2020, will require prior authorization with our Medicare plans.

A complete 2020 listing of services that require prior authorization can be found on the Authorization Information page within Provider Resources at

For commercial authorization requests, call our care management department at 800-236-0208 or 920-720-1600, 8 a.m. to 5 p.m., Monday through Friday. For behavioral health services, call 800-555-3616 or 920-720-1340, 8 a.m. to 5 p.m., Monday through Friday.

Medicare authorization requests, call our care management department with medical or behavioral health authorization requests at 866-709-0019 or 920-720-1602, 8 a.m. to 5 p.m., Monday through Friday.

In our ongoing efforts to better serve our members and provider partners, we are looking forward to these improvements to our prior authorization processes in 2020.

2020 Annual Pharmacy Notification

Important pharmacy information, references and current contact lists are available at

Formulary Overview

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

Network Health manages commercial, individual and family and Medicare formularies. All are very similar with slight differences in tier structures, drug tier placements, utilization management rules and other requirements or restrictions.

Some of our utilization management strategies include prior authorizations, step therapy protocols, quantity level limits and specialty drug restrictions. For commercial, individualand family and Medicare, these rules are created and reviewed independently through our pharmacy and therapeutics committee and are administered through our pharmacy benefits manager, Express Scripts, Inc. (ESI).

Effective January 1, 2020, ESI will administer prescription benefits for our commercial, individual and family and Medicare members, 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 commercial, exchange, Medicare and most self-insured plan members. Mail order for Network Health self-insured participants is handled through the Ascension WI Retail Pharmacy in Wausau. 

2020 Benefits Training and FAQs

Earlier this year, we heard from you that you’d like more information and education on Network Health’s plan benefits. We recently hosted a 2020 Medicare and Individual and Family Plans WebEx training for providers and many of you attended.

If you missed the training or were unable to attend, you can access the training slide deck at the link below. In addition, we collected the frequently asked questions and you can reference the answers in the FAQ document. Below, you’ll find some highlights on changes and the new benefits being added.

2020 Medicare and Individual Family Plans Benefit Training

Provider FAQ

If you'd like a copy of the live recording, please reach out to your Network Health Provider Operations Manager.

  • Jill Stoken 920-720-1505
  • Liz Gillis 920-720-1517
  • Natalie Knaack 920-720-1644
New $25 Insulin Program for Commercial Members

Beginning January 1, 2020, Network Health is introducing the Patient Assurance Program which provides less expensive insulin options for our commercial members—including those who get insurance through their employer and those who purchase on their own.*

The Patient Assurance Program lists insulin as a preventive drug, which brings preferred brand (tier 3) insulin copayments down to $25 for a 30-day supply or $75 for a 3-month supply. This allows all commercial members—even those on HSA-qualified plans—to access this $25 insulin benefit before they meet their deductible.

To determine which drugs fit into this program, you can view and search our drug lists on the Look Up Medications page of our website.

*Not available for Medicare plans, some self-insured plans and transitional, grandmothered or grandfathered commercial plans.

Pharmacy Network Updates
On January 1, 2020, Network Health pharmacy benefits for our employer and individual commercial products will be administered by Express Scripts, Inc.® (ESI). ESI has been the pharmacy benefits manager for Network Health Medicare members since 2005, so they are not impacted by this change. By adding commercial members to the same PBM, we will create additional efficiencies and cost savings.

Beginning August 1, 2019, Walgreens pharmacies became in-network for all Network Health members. All other pharmacy benefits remain the same until January 1, 2020.

With the PBM change, many large retailers, including Walgreens, Costco, Meijer, Pick ‘n Save, Walmart and Sam’s Club will continue to be in-network. CVS/caremarkTM (including Target) pharmacies will be out-of-network beginning January 1, 2020.

If members currently use a CVS/caremark pharmacy, we have advised them to refill prescriptions in December 2019 to cover their medication needs until they transfer their pharmacy files to an in-network pharmacy on January 1, 2020.

Members and providers can search the entire updated pharmacy network, both retail and mail order, through our Find a Pharmacy tool starting November 1, 2019.

Medicare and Individual and Family Plan Highlights
2020 Network Health Medicare Advantage plan documents are available on the Plan Materials page of A few highlights include the following.

  • To ensure all of our Medicare Advantage members have ID cards early this year, members received their 2020 ID card in October.
  • Enhancements to our Medicare plans include the following.
    • No drug deductible on Tier 1-3 medications (most plans with drug coverage)
    • A caregiver benefit has been added to all plans, offering support and local resources for members who are caring for other loved ones and for members’ authorized representatives
    • An over-the-counter drug benefit of $50 per quarter has been added to some plans
    • Wellness rewards are being added for our NetworkPrime (MSA) members to encourage them to have their annual wellness visit, routine labs and get a flu shot.

2020 individual and family plan information is now available on the Individual and Family Available Plans page of Our 2020 plans are being offered at reduced rates and feature the following. These plans are all HMO plans, so providers must refer individual and family members to in-network providers. Services will not be covered if an individual or family plan member is referred to a provider outside the network. In-network providers can be found at New for 2020, providers may refer members throughout our individual and family plan northeast and southeast Wisconsin service area. The provider network is combined across both areas.

  • $0 preventive care services
  • $0 annual vision exam through EyeMed
  • $0 routine dental exam, cleaning and x-ray through Argus Dental
  • $0 virtual doctor visits (for some plans, deductible must be met first)
  • A Momentum healthy rewards program, where members can earn a $100 gift card for completing four tasks essential to their health and wellness.
The individual and family plan enrollment period runs from November 1–December 15. The Medicare Annual Enrollment period runs from October 15–December 7. 

Save the Date for December Practice Manager Meetings

Network Health is currently planning our Practice Manager Meetings for December. Watch for an email invite to sign up soon. The meetings will be held at the following locations and times.
  • 1570 Midway Place, Menasha, December 12, 12 p.m. to 1 p.m.
  • 16960 West Greenfield Road, Suite 5, Brookfield, December 10, 12 p.m. to 1 p.m.

Network Health Organizational Changes to Better Serve You

At Network Health, we’ve recently made a few changes in our network development department to better serve our providers.

Cynthia Schmidt has been hired as Network Health’s Director of Managed Care Contracting to head up our contracting team with Dawn Malueg and Linda Jeanty. Under Cynthia’s leadership, Dawn and Linda will be accountable for negotiating/amending contracts, annual contractual updates, single case agreements, provider/facility information updates, network adequacy and they’ll serve as liaisons between providers and credentialing.

Melissa Anderson, Network Health’s Director of Provider Operations, will head up our provider operations team with Jill Stoken, Liz Gillis and Natalie Knaack. Under Melissa’s leadership, Jill, Liz and Natalie will be accountable for provider orientation/education, payment policies, practice/specialty meetings and they’ll serve as liaisons between providers and claims, customer service, care management and payment integrity. The provider operations team is also accountable for working with providers on contract questions post signature.

These changes will allow us more time to focus on the specific needs of our providers.

If you have any questions about the changes, feel free to contact Cynthia Schmidt at or Melissa Anderson at

Network Health Holidays

Network Health offices will be closed on the following dates.

  • Thursday, November 28
  • Friday, November 29
  • Tuesday, December 24
  • Wednesday, December 25

Check Run Calendar

Below are the check run dates for November month end and December month end.

  • Sunday, November 24, will be moved to Tuesday, November 26, for a check date of November 27, because of the holiday.
  • Wednesday December 18 will be a full check run the same as a Sunday night. We will skip the Sunday, December 22, check run because of the holiday.
  • Wednesday December 25 will be a full check run the same as a Sunday night. We will skip the Sunday, December 29, check run.
  • Monday, December 30, for a check date of December 31.


  • PDPM (patient driven payment model) methodology is active for Medicare Advantage only. For contracted providers, commercial claims will be reimbursed at the 2018 RUG Rates. PDGM (patient driven group model) methodology will be effective on January 1, 2020, and Network Health will be implementing it for Medicare Advantage only. For contracted providers with commercial contracts, commercial claims will be reimbursed per the contracted rates.
  • For those that completed our Annual Provider Satisfaction survey, thank you. We are compiling the results and will be developing action plans across all functional areas of Network Health.
  • If you received an email request to complete an Access to Care survey, please take five minutes to provide us updated information regarding next appointment access by the end of the year.
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