Effective January 1, 2024, Highmark is making some changes to the medications on our Medicare Part D formularies. These changes will ensure the safe and effective use of prescription medications while ensuring they are affordable for our members.
Most members with Medicare Part D coverage will be able to receive up to a 100-day supply for generic medications on Tier 1 and Tier 2 of Highmark’s formularies. When appropriate, providers are encouraged to write prescriptions for this higher day supply. Some examples of Tier 1 or Tier 2 drugs eligible for a 100-day supply include Lisinopril, Metformin, and Atorvastatin.
If you are unsure whether the member has this benefit, or what tier the medication is, see our Tip Sheet, which is accessible from the left menu on the Provider Resource Center (PRC) under PHARMACY PROGRAM/FORMULARIES and then click Medicare Formularies.
Some medications may be removed from the formulary or have new restrictions in 2024. More information on the types of changes can be found in the Definition of Status and Definition of Restrictions sections of the online formularies, which are available on the PRC. Select PHARMACY PROGRAM/FORMULARIES from the left menu and then click Medicare Formularies.
Beginning November 10, 2023, Highmark will send letters to prescribing providers and members with more information about these changes. Once you receive your letter, you can either submit a coverage determination or request a different drug that Medicare Part D would cover.
If your patients are still taking these affected medications, please consider changing them to a covered formulary alternative or request a coverage determination, so that they can continue receiving the same medication.
Coverage determination requests for the 2024 plan year may be requested beginning November 13, 2023. If a coverage determination is submitted, Highmark will review the request and notify you and the member of the decision.
This form is also available on the Provider Resource Center under FORMS > Pharmacy Prior Authorization Forms > Request for Non-Formulary Drug Coverage.