Plan Policies / Formulary Information

The Highmark Medicare-Approved Drug Formulary is a list of FDA-approved prescription drug medications reviewed by our Pharmacy and Therapeutics (P&T) Committee. This Committee is comprised of network physicians and pharmacists who select products on the basis of their safety, efficacy, quality and cost to the plan. The formulary is designed to assist in maintaining the quality of patient care and containing cost for the patient’s drug benefit plan. Formulary drugs are those reviewed and recommended for inclusion by Highmark’s P&T Committee. These drugs are selected based on their safety, efficacy, quality, and cost. The P & T Committee approves revisions to the formulary on a quarterly basis; updates will be provided to reflect such additions.

Physicians are requested to prescribe medications included in the formulary whenever possible. The Pharmacy Affairs department will monitor provider-specific formulary prescribing and communicate with providers to encourage use of formulary products.

The Highmark Medicare-Approved Drug Formulary is divided into major therapeutic categories for easy use. Products that are approved for more than one therapeutic indication may be included in more than one category. Drugs are listed by brand and generic names. Most dosage forms and strengths of a drug are included in the formulary.

Highmark covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Benefit related questions should be referred to the telephone number located on the member's ID card.

Information About Formulary Changes

Products may be removed from the Highmark Medicare-Approved Select/Choice Drug Formulary twice a year, January 1st and July 1st, after a minimum of 60 days notification to members, authorized prescribers, CMS (Centers for Medicare & Medicaid Services), SPAPs (State Pharmaceutical Assistance Programs), network pharmacies, and pharmacists. The formulary may change during the year. Changes to the Highmark Medicare-Approved Select/Choice Drug Formulary will be posted in October and May of each calendar year. The formulary may change on January 1, 2008. Please contact Highmark Member Services using the phone number on the back of your identification card for further details.

To find formulary changes for 2009, click on the 2009 Formulary Changes tab.

For information on Highmark's Medicare Part D Exceptions and Appeals Process click on the following link: Medicare Appeals Information

To obtain a physician request form, click on the following link: Medication Request Form

To access the CMS Medication Request form, click on the following link: CMS Coverage Determination Form

In order to authorize an individual to act as your representative for requesting a coverage determination or appeal, click on the following link: Appointment of Representative

For information on Highmark's Medicare Part D Transition process, click on the following link: Medicare Transition Process

For information on Highmark's Medicare Part-D prior authorization policies, click on the following link: Medicare Pharmacy Prior Authorization Policies

To access the Highmark Direct Claim form, click on the following link: Direct Claim Form: General

To access the Highmark Direct Claim form for vaccine administration fees, click on the following link: Direct Claim Form: Vaccine Administration

M0021_S5593_08_1078 (11/2008)

Pending CMS Approval