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Prescription Drug Policies

Prescription Drug Conditions, Limitations, Exceptions, and Appeals

The Highmark Medicare-Approved Prescription Drug Formulary is a list of all covered Part D drugs. The prescription drugs on this list are selected by a team of doctors and pharmacists and are updated on an on-going basis. To find a prescription drug on this list, use our Find a Prescription Drug tool.

The sections below provide important information about your Part D drug plan policies and coverage.

Access Requirements

Highmark has contracts with pharmacies that equal or exceed Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area. Highmark has a large national network of more than 58,000 pharmacies, including chain and independent drug stores.

Network Limitations

-      Enrollees must use network pharmacies or the Highmark mail order pharmacy service to receive covered Part D drugs except under emergency or non-routine circumstances.

-      When obtaining prescriptions from pharmacies outside the network, the coverage may be less.

-      In the event that you use a pharmacy outside of our national pharmacy network, you may need to pay for the drug in full and submit a claim to Highmark for reimbursement.

-      Eligible out-of-network claims will be paid at the rate the drug would have been paid for if you had purchased the drug from a Highmark network pharmacy.

-      You will be responsible for the difference between the amount Highmark would have paid a network pharmacy and the price you paid, in addition to your applicable copayment or coinsurance.

Days Supply

Prescriptions for 1-31 days will require the same copayment as a 31-day supply and any prescriptions beyond 31 days (32-90 days) will be charged the same copayment as a 90-day supply.

Prescriptions obtained at a retail pharmacy for 32-90 days may have a higher copayment than those received through the Highmark mail order pharmacy service.

The Highmark Medicare-Approved Drug Formulary is a list of U.S. Food and Drug Administration (FDA)-approved prescription drug medications reviewed by our Pharmacy and Therapeutics (P&T) Committee. This Committee is comprised of network physicians and pharmacists who select products on the basis of their safety, efficacy, quality and cost to the plan.

The formulary is designed to assist in maintaining the quality of patient care and containing cost for the patient’s drug benefit plan. Formulary drugs are those reviewed and recommended for inclusion by Highmark’s P&T Committee. The P&T Committee approves revisions to the formulary on a quarterly basis; updates will be provided to reflect such additions.

Physicians are requested to prescribe medications included in the formulary whenever possible. The Pharmacy Affairs department will monitor provider-specific formulary prescribing and communicate with providers to encourage use of formulary products.

The Highmark Medicare-Approved Prescription Drug Formulary is divided into major therapeutic categories for easy use. Products that are approved for more than one therapeutic indication may be included in morethan one category. Prescription drugs are listed by brand and generic names. Most dosage forms and strengths of a drug are included in the formulary.

Highmark covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the FDA to be as safe and effective as brand name drugs.

In most cases, your prescriptions are covered under your Highmark plan only if they are filled at a network pharmacy or through our mail-order pharmacy service. A network pharmacy is a pharmacy that has agreed to provide prescription drug benefits at negotiated prices for Highmark members.

We will fill prescriptions at non-network pharmacies under certain circumstances. The following are a few exceptions when we will pay for a prescription filled at a pharmacy outside of our network:

Getting coverage when you travel or are away from the plan's service area:

If you are traveling within the United States and territories and become ill or lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Needing a prescription because of a medical emergency or because you needed urgent care

We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

Other times you can get your prescription covered if you go to an out-of-network pharmacy:

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

-   If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.

- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (such as high-cost and unique drugs).

- If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and is administered in your doctor’s office.

- If you are evacuated or displaced from your residence due to a state or federally declared disaster or health emergency. 

Before you fill your prescription in any of these situations, call Member Service to see if there is a network pharmacy in your area where you can fill your prescription. If you go to an out-of-network pharmacy, you maybe responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription (rather than paying just your copayment) when you fill your prescription. When you return home, you can ask us to reimburse you for our share of the cost by submitting a claim form. Simply submit your claim and your receipt to the address on your Highmark ID card. Upon receipt, we will make an initial coverage determination on the claim.

You can also download the forms:

Form used to submit pharmacy prescription fees or submit vaccine administration fees

Direct Claim Form

 

Products may be removed from the Highmark Medicare-Approved Drug Formulary — after a minimum of 60days notification to members, authorized prescribers, CMS (Centers for Medicare & Medicaid Services), SPAPs (State Pharmaceutical Assistance Programs), network pharmacies, and pharmacists. The formulary may change during the year, and the formulary website will be updated with any changes. Please contact Highmark Member Service using the phone number on the back of your identification card for further details on formulary changes.

For information on our Medicare Part D Transition process, click the following link:

Medicare Transition Process

Medication Therapy Management (MTM) Program

The Highmark Medication Therapy Management (MTM) program is an integrated pharmacy experience that helps Medicare members with chronic conditions and high prescription costs better manage their medications.

You can learn more about our Medication Therapy Management Program here. For additional information on Highmark's MTM program, please contact member service.

Prior Authorization

Highmark requires you to get prior authorization for certain drugs. This means you will need to get approval from Highmark before you fill certain prescriptions. If you don’t get approval, Highmark may not cover the drug. Our prior authorization policies are in place to ensure the safe and effective use of medications.

Brand Name Drugs vs. Generic Drugs

When a generic version of a brand name drug is available, our network pharmacies must provide you with the generic version. However, if your doctor has told us that no generic substitutions are permitted, then we will cover the brand name drug. Your share of the cost may be greater for the brand name drug.

Quantity Limits

For safety purposes, certain drugs are covered in limited amounts per prescription. For example, Highmark provides up to nine tablets per prescription for the drug Imitrex.

Pharmacy Messaging Alert System

Highmark has a real-time messaging alert system in place to inform pharmacists of potential drug problems. When a pharmacist, who is dispensing a drug, bills Highmark, the computer system performs a series of clinical checks. These will alert the pharmacist of potential drug-to-drug interactions, as well as higher or lower doses than are normally prescribed. These alerts serve to increase the quality and safety of pharmacy and patient interactions.