Formulary drugs are reviewed and recommended by Highmark Wholecare's P&T Committee. Each medicine is chosen based on safety, quality and cost. These drugs should be used by doctors and pharmacists when they are a good fit.
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Highmark Wholecare offers a 90-day supply of select generic medications for diabetes, asthma, cholesterol, blood pressure, mental health and more. Save money on co-pays and make less trips to the pharmacy!
Compounded prescriptions are considered formulary drugs provided they contain at least one listed formulary drug in the final product. A claim for a compounded prescription should be submitted using either the national drug code (NDC) of the most expensive legend ingredient or may be submitted with all NDCs used in the compound. The software should be able to flag the prescription as a "Compounded Prescription." The compound ingredient cost must be manually entered by the pharmacy when submitting the most expensive legend ingredient. If the multi-ingredient compound logic is used the compound cost will be automatically calculated. Payment will only be made for FDA approved drugs and drugs not excluded from payment by Medical Assistance.
Generic substitution is required when an equivalent generic drug is available. Generic drugs are subject to specific reimbursement levels, such as Maximum Allowable Cost (MAC) price reimbursements. Drugs that are available in generic form will appear in bold. The bold font indicates that the generic drug product is on the formulary, but the branded product is not. Requests for "Brand Necessary" medications will be considered a nonformulary medication request and will require authorization. The Highmark Wholecare Request for Nonformulary Drug Coverage Form must be submitted with sufficient documentation to substantiate medical necessity of the brand name medication. Physicians are encouraged to prescribe generic medications whenever clinically appropriate.
For certain drugs, Highmark Wholecare limits the amount of the drug that Highmark Wholecare will cover. For example, Highmark Wholecare provides coverage for 9 tablets of sumatriptan (generic Imitrex) 100mg every 30 days. Prescriptions in excess of the covered monthly quantity would require a medical exception request from the prescribing physician. Medications with quantity limits are denoted by QL in the online formulary. Quantity limits are based on the FDA recommended dosing.
Non-covered drugs include the following categories:
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Highmark Wholecare ONLY covers Food and Drug Administration (FDA) approved drugs.