Prescription Drug Benefits

Your Highmark Wholecare D-SNP includes prescription drug benefits as a part of your Medication Benefits. It’s important to know how your prescription drug benefits work so you stay healthy.

Your Zero Cost Prescriptions

Because you can get Medicare coverage and Medicaid coverage with your D-SNP, some of your Medicare covered medications are covered under your Medicaid benefits.  This is called “Extra Help.”  It gives you a $0 copay for most covered Medicare Part D prescription drugs, meaning you won’t have to pay Medicare Part D covered drugs.

As a reminder, please update Highmark Wholecare if your personal information changes. Call Member Services at 1-844-339-7684 (TTY 711).

Using Your Drug List

A list of your D-SNP approved drugs, also known as a formulary, is available to you.  A team of doctors and pharmacists helped select the drugs on your D-SNP Drug List.

Your D-SNP Drug List includes Medicare Part D covered drugs, like:

  • Brand name drugs
  • Generic drugs (same active ingredients as brand name drugs)
  • Biosimilars (protein-based drugs)

When changes are needed, your Drug List will get updated.

If you need to take medication, you and your doctor can use your Drug List to:

  • Confirm your D-SNP covers your drug
  • Learn about drug costs
  • Learn about ways to get your medicine

Note: if a Medicare covered medication is not in the Drug List, it’s usually not covered by your D-SNP.

Cost-Sharing Tiers

Your Drug List uses a system to group drugs into categories by type and cost, also called cost-sharing tiers. Every drug in your D-SNP Drug List is placed into one of five cost-sharing tiers. In general, the higher the tier number, the more a drug costs:

  • Tier 1 includes preferred generics
  • Tier 2 includes generics
  • Tier 3 includes preferred brands
  • Tier 4 includes non-preferred drugs
  • Tier 5 includes specialty tier drugs


Filling Your Prescriptions

When you need a prescription filled, you’ll have a few ways to get your medication.

Using Network Pharmacies

Your D-SNP uses a group of approved Medicare pharmacies, also known as a pharmacy network, that has many locations for your convenience. You must visit a network pharmacy to use your D-SNP prescription benefits.

When you fill your prescriptions at a network pharmacy and present your membership card, you won’t need to pay for most prescriptions. You can use any network pharmacy of your choice. Remember, if you visit an out-of-network pharmacy, it may not be covered.

To find a network pharmacy near you:

  • Use our Pharmacy Finder tool
  • Check your Pharmacy Directory
  • Call Member Services at 1-844-339-7684 (TTY 711)

Note: If you don’t have your membership card and the pharmacy can’t confirm your D-SNP information, you may have to pay for your prescription in full and get paid back later.

Mail Order

For some prescriptions, like medications you take on a regular basis, you can use a mail order service. When you sign up for mail order, you’ll order a 90-day supply of your prescription and have it mailed to your address. Usually, orders don’t take more than 10 days.

Medicare approved drugs that can be ordered by mail are marked in your D-SNP Drug List.

If you’d like to get your prescriptions by mail, please call Member Services at 1-844-339-7684 (TTY 711).

Getting Prior Authorization

For certain drugs, your doctor or health care provider may need to have Highmark Wholecare approve a medication before your D-SNP covers it. This is called prior authorization. When this happens, a prior authorization form is sent in for review. In some cases, your prescription may not get covered.

Following Quantity Limits

As a safety measure, your D-SNP may place limits on certain prescription doses.  For example, if it’s normally considered safe to take only one pill per day of a certain drug, your prescription benefits may only cover one pill per day.

Help is Available

If you have questions about your D-SNP prescription drug benefits, your Evidence of Coverage (EOC) has more information. You can review your Evidence of Coverage below. 

2024 Diamond EOC
2024 Diamond Southeast PA EOC
2024 Ruby EOC
2024 Ruby Southeast PA

2023 Diamond EOC
2023 Diamond Southeast PA EOC
2023 Ruby EOC
2023 Ruby Southeast PA

You can also call Member Services at 1-844-339-7684 (TTY 711).