Here’s how Highmark Health Options Duals (HMO SNP) medication benefits work.
Your Highmark Health Options D-SNP prescription drug benefit includes Medicare Part D prescription drug coverage. When your doctor writes a prescription, your drug coverage includes:
Remember to show your Highmark Health Options Duals or Highmark Health Options Duals Select card each time you visit your pharmacy.
In 2026, the amount you’ll pay for your prescription drugs depends on the level of Extra Help you get.
Drug copays range from $0-$5.10 for generic medications and $0-$12.65 for brand/non-preferred medications. If you don’t receive Extra Help, your prescription costs are 25% per medication fill.
Note, insulin being used for a pump may have a copay up to $35 for a one-month supply.
Your Part D deductible is $615. If you’re in a program that helps pay for your drugs (Extra help) you won’t pay a deductible.
Please review your Formulary resources and documents for more information.
The prescription drugs Highmark Health Options Duals and Highmark Health Options Duals Select cover are shown in a formulary, also called a drug list. Your formulary shows which Medicare Part D prescription drugs are covered under your Medicare Part D benefits. It also stays updated with any drug restrictions.
Your Highmark Health Options Duals and Highmark Health Options Duals Select prescription drug benefits follow rules and coverage limits called step therapy for medically administered drugs. In some instances, like injectables or biologics, step therapy has you try a preferred drug first before nonpreferred drugs are covered.
If your drug is not on the formulary (drug list) or is restricted, here are some things you can do to help avoid missing doses.
In some cases, your D-SNP can offer you a temporary drug supply if your drug isn’t on the drug list or if it’s restricted. This can give you and your doctor time to review other options or ask for a medication exception.
To be considered for a temporary supply, some rules must be met, like:
As an example, you may need a prior authorization from us before you can fill your prescription. If this happens, you should talk to your doctor to decide if you should consider a covered drug or request a formulary exception so that the drug you take gets covered.
In some cases, your drug may get covered during your first 90 days as a Highmark Health Options Duals member.
As examples, the following members can get a temporary supply of each drug that’s not on our formulary or if the ability to get your drugs is limited:
If you were a D-SNP member last year and aren’t in a long-term care facility
For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of the calendar year if your claims history shows you were previously on the drug and Highmark Health Options Duals made formulary changes from the previous year that negatively impacted you. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of the calendar year.
If you’re a new D-SNP member and aren’t in a long-term care facility
For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.
If you’re a new D-SNP member and live In a long-term care facility
For one time only, your D-SNP will cover a supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 31 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 31 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.
If you’ve been a D-SNP member for more than 90 days, live in a long-term care facility and need a supply right away
Your D-SNP will cover one 31-day supply, or less if your prescription is written for fewer days while an exception or prior authorization is requested. This is in addition to the above long-term care transition supply.
If your drug isn’t on your D-SNP drug list or is restricted, you can change to another drug.
In 2026, you can call Duals Member Services at 1-855-401-8251 (TTY 711) or Duals Select Member Services at 1-844-72-5837 (TTY 711) to ask for a list of covered drugs that treat the same medical condition. Sharing this list with your doctor can help you both decide if you should make medication changes.
You and your doctor can request an exception by asking Highmark Health Options Duals to cover the drug or remove restrictions from the drug. If your doctor agrees that you have medical reasons that justify asking for an exception, he or she can help you make the request.
We want you to be safe when you take your medicine. That's why we have quality assurance programs and policies to check your prescriptions. Here's what our quality assurance includes:
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