This page explains the Self-Administered Injectable or Oral Biotechnology Drug Program.
Highmark has taken steps to help manage the rising costs of medications by requiring members to obtain certain specialty drugs through an exclusive specialty provider(s). Exclusive specialty provider(s) vary by group.
Determining what specialty pharmacy my patient is required to use
Q: How do I know what specialty provider my patient is required to use to obtain their self-administered injectable or oral specialty drug?
A: Determine what type of plan the member has:
- Verify member benefits and determine if your patient is required to use an exclusive specialty provider(s) by one of the following:
- Does your patient have an exclusive specialty pharmacy that they must use?
- YES - Once the benefit is determined follow the drug list link of the exclusive specialty provider(s) below to obtain the list of drugs that are mandatory. The contact information and website/referral information is also provided.
- NO - Some groups do not have an exclusive specialty pharmacy; these patients are able to fill at any in-network specialty pharmacy of their choice.
- UNSURE - Call the member services phone number on the back of your patient’s ID card to confirm.
Due to Medicare Part D prescription drug coverage regulations, there is no mandatory program for Medicare Advantage patients. Patients have the option to obtain their specialty drugs through any in network pharmacy.
Q: What do I do if my patient requires a prior authorization on their specialty drug under the pharmacy benefit?
A: A prior authorization may be required based on your patient’s pharmacy benefit. If a prior authorization is required, please submit the information below to the Highmark Prior Authorization Department by faxing to 1-866-240-8123.
- Member name, DOB, ID#
- Drug, strength, quantity requested
- Diagnosis, alternatives tried
- Other pertinent clinical information (to view the criteria, please access our pharmacy clinical policies using the search feature.
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Last updated on 4/27/2021