Your Highmark Wholecare D-SNP Formulary, also known as Drug List, shows you every covered drug under your prescription drug benefits. All drugs approved for coverage are:
Your Drug List also groups covered drugs by type and cost, also known as tiers. If a Medicare covered medication is not in the Drug List, it’s usually not covered by your D-SNP.
You can quickly and easily search the Diamond and Ruby D-SNP Drug List.
If your drug is not on the 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 Wholecare D-SNP 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.
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 Wholecare 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.
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.
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.
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.
You can call Member Services at 1-800-392-1147 (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 Wholecare 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.
If your medication isn’t covered under your D-SNP prescription drug benefits, you can ask Highmark Wholecare Medicare Assured to make a coverage rule exception.
When you need to request a medication exception, you can ask your D-SNP to:
When you are requesting a formulary or utilization restriction exception you must submit a statement from your doctor supporting your request. Your prescribing doctor or professional can either call Highmark Wholecare or complete the Medicare Request for Drug Coverage Form
CoverMyMeds is a platform that helps patients get the medication they need to live healthy lives by streamlining the prior authorization (PA) process for providers and pharmacists.
You can visit the CoverMyMeds website to create a free account or log in to your existing account before completing your request.
You can mail your request to:
Highmark Wholecare Medicare Assured
P.O. Box 22158
Pittsburgh, PA 15222-1222
You can fax your request to 1-888-447-4369.
Note, if you’re sending in your own request, your prescribing doctor or professional must send a statement to support your request for coverage determination. The statement should also detail if your health could be seriously harmed by waiting three days for a request decision.
You should contact us to ask us for an initial coverage decision on your formulary or utilization restriction exception. Generally, we must make our decision within 72 hours of getting your doctor’s supporting statement.
In most cases, Highmark Wholecare will only approve your request for an exception if the alternative drugs included on your D-SNP formulary or additional utilization restrictions aren’t as effective in treating your condition and/or would cause adverse medical effects.
If your request for exception is denied, you have the right to request Reconsideration (redetermination) for this decision.
If you’re a Pennsylvania resident, you can call:
1-800-685-5209 (TTY 711)
8 a.m. – 8 p.m. ET
October 1 - March 31: 7 days a week
April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday
You can complete the Request for Redetermination Formand mail it to:
Attention: Appeals & Grievances
P.O. Box 22278
Pittsburgh, PA 15222
Note, your doctor may make this request for you. You can also hand-deliver your Redetermination Form if preferred. Note, if someone is filing a request on your behalf, you must include a completed Highmark Wholecare Medicare Assured Appointment of Representative Formto give this person permission.
You can fax your Request for Redetermination Formto us at 412-255-4503.
If you have questions on how your medication formulary or exemptions work, please review your EOC. You can also call Member Services at 1-800-392-1147 (TTY 711).