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Health Plan Options |
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This email is intended for producers with business in DE, PA, NENY, WNY, and WV. NEW POLICY REGARDING DIABETES GLP-1 DRUGS & MEMBER COMMUNICATIONS AS TO COVERAGE In an effort to continue providing the best coverage for our members while ensuring little to no disruption, Highmark has announced a change to weight loss GLP-1 drug coverage. This will allow for competitive pricing and cost management for our clients and their enrollees. Please read below for important policy updates and steps being taken to educate members and their providers.
- Highmark reviews weight loss GLP-1 (Wegovy and Saxenda) for our clients that cover obesity agents when clients have Other Managed Prior Authorization turned on (have P.A.).
- Highmark will begin to review diabetic GLP-1 (Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) for new starts to therapy on September 15th for clients with some of our smart edits/step therapy turned on (MRxC or Deterrent/Patent Extenders). In order to receive coverage, members must have a diagnosis of type-2 diabetes. New users with a history of a different diabetes medication in pharmacy claims will not be subject to the prior authorization and will receive a paid claim at point of sale.
- Notice (sample) will be sent to existing users and their prescribers on September 1st. Those members will be subject to a prior authorization beginning November 1st . In order to receive coverage, members must have a diagnosis of type-2 diabetes. Existing users with a history of a different diabetes medication in their claims history, diagnosis of type-2 diabetes or obesity (if their plan covers obesity medications) will not be subject to authorization and will continue to receive coverage of their medication without interruption.
Should you have any questions, please contact your Pharmacy Sales Consultant or Client Manager. |
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Highmark Inc. is an independent licensee of the Blue Cross Blue Shield Association. Insurance or benefit administration may be provided by or through Highmark Inc. or one of its affiliated Blue companies. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies serve Blue Cross Blue Shield members in the 29 counties of western Pennsylvania, 13 counties in northeast Pennsylvania, the state of West Virginia plus Washington County, Ohio, and the entire state of Delaware. Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. |
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This email and any attachments contain important information about Highmark, including its products, customers and business processes, and may include information which Highmark considers to be confidential and proprietary ("the Highmark Information"). The Highmark Information is intended solely for the use of the individual or entity to which it is addressed, including employees of that entity with a need to access such information. Unauthorized use, disclosure or copying of the Highmark Information, including the posting of such information on a website or social media sites that can be accessed by third parties, is strictly prohibited.
® Highmark is a registered mark of Highmark Inc.
© 2016 Highmark Inc., All Rights Reserved
120 Fifth Avenue Pittsburgh, PA 15222 USA
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