Network Health Medicare Advantage Plans

Transcription

1 Network Health Medicare Advantage Plans Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier Pharmacy (PPO) Network PlatinumSelect (PPO) NetworkCares(SNP PPO) 2016 Pharmacy Directory This pharmacy directory was updated on 12/18/2015. For more recent information or other questions, please contact Network Health Medicare Advantage plans customer service at or, for TTY users, , 24 hours a day/seven days a week, or visit NetworkHealthMedicare.com. Network Health Medicare Advantage plans are PPO plans with a Medicare contract. NetworkCaresis a PPO SNP plan with Medicare contract and a contract with the Forward Health Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage plans depends on contract renewal. The benefit information is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change January 1 of each year. NetworkCaresis available to anyone who has both Medical Assistance from the State and Medicare. Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. The formulary and pharmacy network may change at any time. You will receive notice when necessary. As an enrollee of our plan, you can get a long-term supply (up to 90 days) of drugs shipped to your home using our plan s network mail order delivery program. Usually you will receive your mail order prescriptions within 14 calendar days. If your order does not arrive within the estimated timeframe, call Express Scripts Customer Service at (TTY ), 24 hours a day/7 days a week. H5215_619p1r2_ Accepted

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3 TABLE OF CONTENTS Introduction Mail Order Pharmacy Home Infusion Pharmacies Long-Term Care Pharmacies Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Pharmacies NETWORK HEALTH 1570 Midway Place PO Box 120 Menasha, WI Customer Service TTY hours a day/seven days a week NetworkHealthMedicare.com

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5 Introduction This booklet provides a list of Network Health Medicare Advantage plan s network pharmacies. To get a complete description of your prescription coverage, including how to fill your prescriptions, please review the Evidence of Coverage and Network Health Medicare Advantage plan s formulary. When this pharmacy directory refers to we, us, or our, it means Network Health Insurance Corporation. When it refers to plan or our plan, it means Network Health Medicare Advantage Plans. We call the pharmacies on this list our network pharmacies because we have made arrangements with them to provide prescription drugs to plan members. In most cases, your prescriptions are covered under Network Health Medicare Advantage plans only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your prescription but can switch to any other of our network pharmacies. We will fill prescriptions at non-network pharmacies under certain circumstances as described in your Evidence of Coverage. All network pharmacies may not be listed in this directory. Pharmacies may have been added or removed from the list after this directory was printed. This means the pharmacies listed here may no longer be in our network, or there may be newer pharmacies in our network that are not listed. This list is current as of December 18, For the most current list, please contact us. Our contact information appears on the front and back cover pages. Changes to our pharmacy network may occur during the benefit year. An updated Pharmacy Directory is located on our website at NetworkHealthMedicare.com. You may also call customer service for updated provider information. You can go to all the pharmacies on this list, but your costs for some drugs may be lower at pharmacies in this list that offer preferred cost sharing. We have marked these pharmacies with (*) to distinguish them from other pharmacies in our network that offer standard cost sharing. Cost sharing information can be found in the Summary of Benefits. You can get prescription drugs shipped to your home through our network mail order delivery service which is called Express Scripts Home Delivery. For more information, please contact us or see the mail order section of this pharmacy directory. If you have questions about any of the above, including for instructions on how to submit claims for prescriptions that you had to fill at a non-network pharmacy, please see the first and last cover pages of this directory for information on how to contact us. 1

6 This directory contains the different types of pharmacies in our network. These pharmacies are listed alphabetically by community. To locate a participating pharmacy, find the community nearest you and check the listing of participating pharmacies. Call customer service (phone numbers are located on the front and back covers of this booklet) or visit our website at NetworkHealthMedicare.com for additional information. * Preferred Pharmacy Legend # Extended Supply Pharmacy. This pharmacy can provide an extended day supply of medications (up to a 90-day supply). 2

7 Algoma 801 Jefferson St Algoma, WI (920) Appleton Consumer Prescription # * 2310 W College Ave Appleton, WI (920) Copps Food Center 2700 N Ballard Rd Appleton, WI (920) Copps Food Center 511 W Calumet St Appleton, WI (920) CVS # 1485 Oneida St Appleton, WI (920) CVS # 700 W Wisconsin Ave Appleton, WI (920) Fox Valley Hemo and Oncology # * 1531 S Madison St STE 250 Appleton, WI (920) Sam's Club # * 1000 N Westhill Blvd Appleton, WI (920) Shopko Express Pharmacy # * 2101 E Evergreen Dr Appleton, WI (920) Shopko Express Pharmacy # * W3208 Van Roy Rd Appleton, WI (920) W Northland Ave Appleton, WI (920) Target 1800 South Kensington Dr Appleton, WI (920) Target 4301 W Wisconsin Ave STE 42 Appleton, WI (920) E Calumet St Appleton, WI (920) N Mutual Way Appleton, WI (920) S Oneida St Appleton, WI (920) N Meade St Appleton, WI (920) E Calumet St Appleton, WI (920) W College Ave Appleton, WI (920) W Northland Ave Appleton, WI (920)

8 Ashwaubenon 2301 S Oneida St Ashwaubenon, WI (920) Lime Kiln Rd Bellevue, WI (920) Berlin Cedar Grove 313 S Main St Cedar Grove, WI (920) Beaver Dam Marshland Pharmacy # 705 S University Ave Beaver Dam, WI (920) Park Ave Beaver Dam, WI (920) Field Pharmacy # 135 W Huron St Berlin, WI (920) W861 County Road F Berlin, WI (920) Brillion Chilton 810 S Irish Rd Chilton, WI (920) W Calumet St Chilton, WI (920) Thrifty White Drug # * 609 N Spring St Beaver Dam, WI (920) Francis Ln Beaver Dam, WI (920) Park Ave Beaver Dam, WI (920) Bellevue Costco # * 2355 Costco Way Bellevue, WI (920) W Ryan St Brillion, WI (920) Brownsville Agnesian 900 Main St Brownsville, WI (920) Campbellsport The Village Apothecary # * 110 W Main St Campbellsport, WI (920) Clintonville Erickson 8 S Main St STE B Clintonville, WI (715) S Main St Clintonville, WI (715) S Main St Clintonville, WI (715) De Pere 1881 Chicago St De Pere, WI (920)

9 De Pere (continued) CVS # 800 Main Ave De Pere, WI (920) Shopko Express Pharmacy # * 3705 Monroe Rd De Pere, WI (920) N Wisconsin St De Pere, WI (920) Lawrence Dr De Pere, WI (920) S Wisconsin Ave De Pere, WI (920) Main Ave De Pere, WI (920) Denmark Bellin Health Pharmacy # * 595 County Road R Denmark, WI (920) Fond du Lac Agnesian 145 N Main St Fond du Lac, WI (920) Agnesian 912 S Hickory Rd Fond du Lac, WI (920) Agnesian Pharmacy Plus # * 420 E Division St Fond du Lac, WI (920) Wisc American Dr Fond du Lac, WI (920) Kremer 9 N Main St Fond du Lac, WI (920) Pick N Save 55 W Pioneer Rd Fond du Lac, WI (920) Pick N Save 760 W Johnson St Fond du Lac, WI (920) W Johnson St Fond du Lac, WI (920) Target 485 N Rolling Meadows Dr Fond du Lac, WI (920) N Rolling Meadows Dr Fond du Lac, WI (920) E Johnson St Fond du Lac, WI (920) N Main St Fond du Lac, WI (920) W Pioneer Rd Fond du Lac, WI (920) Gillett St Clare Memorial Hosp Phcy # 117 N McKenzie St Gillett, WI (920) Grand Chute Copps Food Center 2400 W Wisconsin Ave Grand Chute, WI (920)

10 Grand Chute (continued) 1305 N Casaloma Dr Grand Chute, WI (920) Green Bay 2253 W Mason St Green Bay, WI (920) Green Brier Rd Green Bay, WI (920) Bellin Health Pharmacy # 1630 Commanche Ave STE 102 Green Bay, WI (920) Bellin Health Pharmacy # 744 S Webster Ave Green Bay, WI (920) Bellin Health Remote Disp # 3263 Eaton Rd Green Bay, WI (920) Copps Food Center 1291 Lombardi Access Rd Green Bay, WI (920) Copps Food Center 1819 Main St Green Bay, WI (920) CVS # 1561 W Mason St Green Bay, WI (920) CVS # 2222 S Webster Ave Green Bay, WI (920) CVS # 2400 Velp Ave Green Bay, WI (920) CVS # 930 Main St Green Bay, WI (920) Krider Pharmacy and Gifts # 1119 W Mason St Green Bay, WI (920) Sam's Club # * 2470 W Mason St Green Bay, WI (920) Shopko Express Pharmacy # * 2585 Lineville Rd Green Bay, WI (920) S Military Ave Green Bay, WI (920) Lineville Rd Green Bay, WI (920) E Mason St Green Bay, WI (920) Bay Park Sq Green Bay, WI (920) Target 1001 Cormier Rd Green Bay, WI (920) Target 2050 Lime Kiln Rd Green Bay, WI (920) Main St Green Bay, WI (920) W Mason St Green Bay, WI (920) N Military Ave Green Bay, WI (920)

11 Green Bay (continued) 1165 W Mason St Green Bay, WI (920) E Mason St Green Bay, WI (920) Main St Green Bay, WI (920) University Ave Green Bay, WI (920) Cardinal Ln Green Bay, WI (920) Green Lake CHN Pharmacy Green Lake # * 762 Commercial Ave Green Lake, WI (920) Horicon Marshland Pharmacy # 700 Washington St Horicon, WI (920) Howards Grove 620 S Wisconsin Dr Howards Grove, WI (920) Iola Sweet Med Prescriptions Plus # * 155 N Main St Iola, WI (715) Kaukauna 2700 Crooks Ave Kaukauna, WI (920) Crooks Ave Kaukauna, WI (920) Kewaunee 802 N Main St Kewaunee, WI (920) Kiel 1001 Service Rd Kiel, WI (920) State Road 67 Kiel, WI (920) Kimberly 800 E Maes Ave Kimberly, WI (920) Kohler 795 Woodlake Rd Kohler, WI (920) Lakewood Nicolet Commercial Rd Lakewood, WI (715) Little Chute Smith 1800 Freedom Rd STE D Little Chute, WI (920) W Main St Little Chute, WI (920)

12 Lomira Aurora Pres Dispensing Center # 375 East Ave STE 1 Lomira, WI (920) Luxemburg Luxemburg 125 School Creek Trl Luxemburg, WI (920) Manitowoc 601 Reed Ave Manitowoc, WI (920) Copps Food Center 3300 Calumet Ave Manitowoc, WI (920) CVS # 701 E Reed Ave Manitowoc, WI (920) HFM 3310 Calumet Ave Manitowoc, WI (920) Manitowoc Pharmacies # * 919 S 8th St Manitowoc, WI (920) Calumet Ave Manitowoc, WI (920) Calumet Ave Manitowoc, WI (920) Calumet Ave Manitowoc, WI (920) Markesan Agnesian 49 S Bridge St Markesan, WI (920) Mayville Agnesian 360 S Mountain Dr Mayville, WI (920) Horicon St Mayville, WI (920) Menasha 1578 Appleton Rd Menasha, WI (920) Racine St Menasha, WI (920) Montello Bentley 25 W Montello St Montello, WI (608) Neenah CVS # 901 S Green Bay Rd Neenah, WI (920) Neenah Hometown Pharmacy # 1415 S Commercial St Neenah, WI (920) Pick N Save 828 Fox Point Plz Neenah, WI (920) Green Bay Rd Neenah, WI (920) Winneconne Ave Neenah, WI (920)

13 Neenah (continued) 1191 W Towne Dr Neenah, WI (920) S Commercial St Neenah, WI (920) New London Jernegan's Health Mart # * 1301 Mill St New London, WI (920) N Shawano St New London, WI (920) N Shawano St New London, WI (920) North Fond du Lac Agnesian 723 Park Ridge Ln North Fond du Lac, WI (920) Oconto Oconto Pharmacy # 1008 Main St Oconto, WI (920) Charles St Oconto, WI (920) Oconto Falls Oconto Falls Pharmacy HM # * 323 E Highland Dr Oconto Falls, WI (920) St Clare Memorial Hosp Phcy # 855 S Main St Oconto Falls, WI (920) Omro Omro 328 E Main St Omro, WI (920) Oshkosh 2101 Bowen St Oshkosh, WI (920) N Westhaven Dr Oshkosh, WI (920) CVS # 1736 W 9th Ave Oshkosh, WI (920) Murdock Hometown Phcy # 1828 Jackson St Oshkosh, WI (920) Pick N Save 1940 S Koeller St Oshkosh, WI (920) Sawyer Street Hometown Phcy # 321 N Sawyer St Oshkosh, WI (920) Schultz 220 N Main St Oshkosh, WI (920) Koeller Rd Oshkosh, WI (920) Smartscript 4041 State Road 91 STE B Oshkosh, WI (920)

14 Oshkosh (continued) Target 1900 S Koeller St Oshkosh, WI (920) S Washburn St Oshkosh, WI (920) Emmers Ln Oshkosh, WI (920) W Murdock Ave Oshkosh, WI (920) S Koeller St Oshkosh, WI (920) Plover Copps Food Center 1850 Plover Rd Plover, WI (715) Plover Rd Plover, WI (715) Crossroads Dr Plover, WI (715) Plymouth 2635 Eastern Ave Plymouth, WI (920) Walton Dr Plymouth, WI (920) Eastern Ave Plymouth, WI (920) Princeton Bentley Drug # * 528 W Water St Princeton, WI (920) Pulaski Healthmart Pulaski 121 N Saint Augustine St Pulaski, WI (920) Ripon Kmart 1200 W Fond du Lac St Ripon, WI (920) Ripon Drug # * 328 Watson St Ripon, WI (920) W Fond du Lac St Ripon, WI (920) Seymour 1010 S Mainline Dr Seymour, WI (920) Shawano Dreier Health Mart 117 S Main St Shawano, WI (715) Kmart 1211 E Green Bay St Shawano, WI (715) ThedaCare 100 County Road B Shawano, WI (715) E Green Bay St Shawano, WI (715)

15 Shawano (continued) 401 E Green Bay St Shawano, WI (715) Sheboygan 2414 Kohler Memorial Dr Sheboygan, WI (920) Superior Ave Sheboygan, WI (920) Glander Prescription Plus # * 3529 Superior Ave Sheboygan, WI (920) Pick N Save 1317 N 25th St Sheboygan, WI (920) Pick N Save 2625 S Business Dr Sheboygan, WI (920) Sheboygan Health Mart 577 S Taylor Dr Sheboygan, WI (920) S Taylor Dr Sheboygan, WI (920) S Taylor Dr Sheboygan, WI (920) Vanguard Dr Sheboygan, WI (920) N 14th St Sheboygan, WI (920) Calumet Dr Sheboygan, WI (920) S Business Dr Sheboygan, WI (920) Sheboygan Falls Target 4085 State Highway 28 Sheboygan Falls, WI (920) Stevens Point Copps Food Center 1500 Pinecrest Ave Stevens Point, WI (715) Kmart 111 Division St N Stevens Point, WI (715) Main St Stevens Point, WI (715) Trigs County Market 1600 Academy Ave Stevens Point, WI (715) Park Ridge Dr Stevens Point, WI (715) Church St Stevens Point, WI (715) Illinois Ave Stevens Point, WI (715)

16 Two Rivers 2219 Garfield St STE 100 Two Rivers, WI (920) Memorial Dr Two Rivers, WI (920) Medicine Shoppe Pharmacy # 1500 Washington St Two Rivers, WI (920) Washington St Two Rivers, WI (920) Waupaca Kmart 830 W Fulton St Waupaca, WI (715) Shopko Express Pharmacy # * 800 Riverside Dr Waupaca, WI (715) W Fulton St Waupaca, WI (715) Stratton Drug Store # * 107 N Main St Waupaca, WI (715) W Fulton St Waupaca, WI (715) Waupaca Hometown Pharmacy # 115 N Western Ave Unit 8 Waupaca, WI (715) Waupun Agnesian 904 W Main St Waupun, WI (920) E Main St Waupun, WI (920) Wautoma 900 E Division St Wautoma, WI (920) CHN N2934 State Road 22 Wautoma, WI (920) N2585 Plaza Rd Wautoma, WI (920) Westfield Bentley 206 S Main St Westfield, WI (608) Winneconne 946 E Main St Winneconne, WI (920) Wittenberg Gwidt 203 E Westgor Ave Wittenberg, WI (715) Wrightstown Bellin Health Remote Disp # * 555 Quality Ct Wrightstown, WI (920)

17 Mail Order Pharmacy You can get prescription drugs shipped to your home through our network mail order delivery service which is called Express Scripts Home Delivery. If you have used mail order services with your current plan before, or if you opt in now, our network pharmacy will automatically fill and ship new prescriptions received directly from your doctors or other prescribers. You may opt out of automatic deliveries of new prescriptions at any time by contacting us. If you never had mail order delivery and/or decide to stop automatic fills of new prescriptions, we will contact you each time we get a new prescription from a provider, to see if you want the medication filled and shipped at that time. This will give you an opportunity to make sure that the correct drug (including strength, amount, and form) will be delivered, and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. Mail Order Pharmacy To refill your mail order prescriptions, please contact us 21 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at (TTY (hearing impaired) should call ). Express Scripts Mail Order # (800) TTY (800)

18 Home Infusion Pharmacies Network Health Medicare Advantage plans will cover Part D drugs used for home infusion therapy if: Your prescription drug is on Network Health Medicare Advantage plans' formulary or you have a formulary exception; Network Health Medicare Advantage plans has approved your prescription drug for home infusion therapy; and Your prescription is written by an authorized prescriber. Home Infusion Pharmacies Affinity Home Care Plus (HI) 2074 American Dr STE A Neenah, WI (715) Chartwell Midwest Wisconsin (HI) 2241 Pinehurst Dr Middleton, WI (608) Coram Specialty Infusion Services (HI) 5345 S Moorland Rd STE 101 New Berlin, WI (262) Home Care Pharmacy (HI) 5665 S Westridge Dr New Berlin, WI (262) IGG of America (HI) 514 Progress Dr STE X Linthicum, MD (877) Ministry Home Care Plus (HI) 1927 N Central Ave STE B Marshfield, WI (715) Nufactor (HI) County Center Dr Temecula, CA (800) Option Care (HI) 985 Avenue of the Cities Silvis, IL (309) Pentech Health (HI) 4 Creek Pkwy STE A Boothwyn, PA (800) ThedaCare Infusion Pharmacy (HI) 1818 N Meade St Appleton, WI (920) US Bioservices (HI) 5100 E Hunter Ave STE 101 Anaheim, CA (800) US Bioservices (HI) 109 Chelsea Pkwy Boothwyn, PA (800) US Bioservices (HI) 501 W 44th Ave Unit A Denver, CO (800) US Bioservices (HI) 8028 Reeder Rd Lenexa, KS (800) Wheaton Franciscan INF Phcy (HI) 5000 W Chambers St Milwaukee, WI (414)

19 Long-Term Care Pharmacies Residents of a long-term care facility may access their prescription drugs covered under Network Health Medicare Advantage plans through the facility's long-term care pharmacy or another network long-term care pharmacy. Appleton Green Bay King HealthDirect IPS (LTC) 3701 E Evergreen Dr Appleton, WI (920) Beaver Dam Thrifty White Drug (LTC) 609 N Spring St Beaver Dam, WI (920) Brownsville Agnesian Pharmacy (LTC) 900 Main St Brownsville, WI (920) De Forest Hometown Long Term Care Phcy (LTC) 643 S Main St De Forest, WI (608) Krider Pharmacy and Gifts (LTC) 1119 W Mason St Green Bay, WI (920) Streus Pharmacy (LTC) 528 N Monroe Ave Green Bay, WI (920) Streus Pharmacy (LTC) 635 Main St Green Bay, WI (920) Greenfield Surety Pro Pharmacy (LTC) 9200 W Layton Ave Greenfield, WI (414) Greenville NCS Healthcare (LTC) N926 Tower View Dr Greenville, WI (800) Wisconsin Veterans Home Phcy (LTC) N2665 County Rd QQ King, WI (715) La Crosse Pinnacle Phcy of La Crosse (LTC) 3235 Airport Rd La Crosse, WI (608) Madison Genoa Healthcare (LTC) 625 W Washington Ave Madison, WI (608) Oakwood Pharmacy (LTC) 6201 Mineral Point Rd Madison, WI (608) Pinnacle Pharmacy (LTC) 2818 Progress Rd Madison, WI (608) Long-Term Care Pharmacies 15

20 Long-Term Care Pharmacies Long-Term Care Pharmacies Madison (continued) Willow Pharmacy (LTC) 2702 International Ln Madison, WI (608) Mayville Agnesian Pharmacy (LTC) 360 S Mountain Dr Mayville, WI (920) Menasha Morton Pharmacy (LTC) 712 Midway Rd Menasha, WI (920) Milwaukee Genoa Healthcare (LTC) W Bluemound Rd STE B Milwaukee, WI (414) Pharmerica (LTC) 9041 W Heather Ave Milwaukee, WI (800) Phoenix Pharmacy (LTC) 1845 N Farwell Ave STE 200 Milwaukee, WI (414) Roeschen's Omnicare Pharmacy (LTC) 5185 S 9th St Milwaukee, WI (414) New London Jernegan's Health Mart (LTC) 1301 Mill St New London, WI (920) Oshkosh LHO Pharmacy (LTC) 225 N Eagle St Oshkosh, WI (920) Ripon Ripon Drug (LTC) 328 Watson St Ripon, WI (920) Two Rivers Medicine Shoppe Pharmacy (LTC) 1500 Washington St Two Rivers, WI (920) West Allis Prescriptions Plus (LTC) W Greenfield Ave West Allis, WI (414) Wittenberg Gwidt Pharmacy (LTC) 203 E Westgor Ave STE 1 Wittenberg, WI (715)

21 Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Pharmacies Only Native Americans and Alaska Natives have access to Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) Pharmacies through Network Health Medicare Advantage plans' pharmacy network. Those other than Native Americans and Alaskan Natives may be able to access these pharmacies under limited circumstances (e.g., emergencies). Bowler Stockbridge-Muncy Hlth Ctr Phy (I/T/U) W12802 County Road A Bowler, WI (715) Indian Health Service/Tribal/Urban Indian Health Program Oneida Oneida Comm Health Center Phcy (I/T/U) 525 Airport Dr Oneida, WI (920)

22 This pharmacy directory was updated on 12/18/2015. For more recent information or other questions, please contact Network Health Medicare Advantage plans customer service at or, for TTY users, , 24 hours a day/seven days a week, or visit NetworkHealthMedicare.com. 18