Pharmacy Benefits Program

This page gives you a brief overview of Highmark's Pharmacy Benefits Program and information on the following topics:

General Information about Pharmacy Benefits

Pharmacy Benefits for Managed Care Members
Highmark administers prescription benefits for almost all members. For those members, the MedcoHealth logo appears on the member's ID card.

Pharmacy Benefits for FreedomBlue Members
Copayments and coverage limitations vary depending on the region, group, and/or direct-pay enrollment. (Some direct pay benefit plans are not available in every region.) All FreedomBlue coverage includes at least the same services as those provided by Medicare.

Most prescription drugs are covered when provided or authorized by the PCP on an outpatient basis and obtained at a Premier contracting pharmacy. The member must still pay applicable copayments.

A member can verify his or her particular drug coverage by calling Member Service at the telephone number shown on the member's ID card or by visiting Highmark's Medicare-Approved formulary site at: http://highmark.medicare-approvedformularies.com.

Mandatory Generic Feature
Many plans include a mandatory generic provision, which requires that if the generic drug exists but the member or physician specifically requests the brand name drug, the member will have to pay the brand name copayment and the cost difference between the brand name drug and the generic drug. For some plans with a mandatory generic provision, if a member requests the brand name drug, but the prescription does not specify "brand medically necessary," the member will be required to pay the difference in cost between the brand drug and the generic drug, in addition to the applicable brand name copayment.

Other Coverage for Pharmacy Benefits
Some members of SelectBlue and PPO Blue may have other prescription drug coverage that is not administered by Highmark.

Coverage for Some Over-the-Counter Drugs
Some over-the-counter medications are available through the closed formulary. A prescription is required for these drugs and the member must obtain the medication through the pharmacy for coverage to apply. The member is charged the generic copayment.

Premier Pharmacy Networks
The prescription drug program offers a wide network of pharmacies and various pharmacy networks, including most national chains and many local, independent pharmacies. (Members receive a directory of pharmacies with their enrollment materials.) Networks and drug benefits may vary slightly, depending upon the member's group and/or managed care program. Pharmacies have point-of-sale technology that confirms a member's eligibility, benefit design and copayment information at the time of dispensing. Managed care members must use one of the participating pharmacies in Highmark's Premier Pharmacy networks. Members may consult their pharmacy directory, visit Highmark's web site at www.highmarkblueshield.com, or call Member Services at the number shown on their ID cards to find a network pharmacy that is conveniently located.

The Formulary

The Highmark Drug Formulary is a list of 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. The Highmark P&T Committee approves revisions to the drug formulary on a quarterly basis; updates will be provided to reflect such additions.

Products are removed from the formulary twice a year, January 1st and July 1st, after a minimum of 30 days notification is given to providers. To obtain a copy of the formulary, contact your Provider Relations representative.

Physicians are requested to prescribe medications included in the formulary whenever possible.

Highmark's Medical and Pharmacy Affairs department monitors provider-specific formulary prescribing and communicates with providers to encourage use of formulary products.

The drug formulary is divided into sections based on the member's plan benefit design. For members with a Highmark Select or Highmark Choice formulary benefit, non-formulary drugs are not covered under a Select formulary benefit or will require a higher co-payment under a Choice formulary benefit. For members with a Highmark Medicare-Approved Select/Choice formulary benefit, non-formulary drugs are not covered under a Select formulary benefit or will require a higher co-payment under a Choice formulary benefit.

The drug formulary is then divided into major therapeutic categories for easy use. Products that are approved for more than one therapeutic indication may be included in more than one category. Drugs are listed by brand and generic names. Most dosage forms and strengths of a drug are included in the formulary.

To view the Highmark Select/Choice Formulary, click here.

To view the Highmark Medicare-Approved Select/Choice Formulary for Medicare Advantage or BlueRx members, click here.

Home Delivery (Mail Service) Service

Home delivery service is an option that groups may select depending on their benefit design. Members may call the Member Services telephone number on their identification card to find out if they have home delivery coverage.

Advantages of Using the Home Delivery Service
Members may prefer to use the home delivery prescription service. This service enables members to obtain up to a 90-day supply of either generic or brand name drugs, for either one or two times the retail generic or brand co-payment, or applicable coinsurance, depending upon the member's benefit plan.

How to Assist Members in Using the Home Delivery Service
If a member must begin taking a new maintenance drug immediately, they may need to have two prescriptions. The member can have one of the prescriptions filled at a local pharmacy to begin taking the medication immediately. (It is recommended that this prescription be written for a two-week supply.) The member can send the other prescription to the home delivery service for up to a 90-day supply.

How Members Use the Home Delivery Service
Members can obtain home delivery forms for maintenance drugs by calling the Member Service telephone number on their ID card, or by calling MedcoHealth directly at: 1-800-903-6228. Once a member places an order, the member's information remains on file. Any subsequent refills do not require an order form. For refills, the member can call the toll-free number, send in the refill form with the applicable co-payment, or visit Highmark's web site at www.highmarkblueshield.com.

Last updated on 9/14/2017

 

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