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This email is intended for producers with business in Delaware, New York, Pennsylvania, and West Virginia.

Pharmacy Blast: Pharmacy Program Updates and Reminders

We continuously review our coverage levels and medical policies to ensure they remain appropriate and effective for the markets we serve. This ongoing evaluation helps us adapt to evolving healthcare needs and provide relevant benefits to our members.

We have several important pharmacy updates and reminders to share, and to make this information more accessible, we’ve consolidated them into a single, comprehensive message. This approach aims to provide you with all the latest details.

UPDATE: GLP-1 Medications

Recent evidence has expanded the understanding of anti-obesity GLP-1 medications, showing their effectiveness in treating conditions like obstructive sleep apnea, preventing cardiovascular events, and managing metabolic-dysfunction associated steatohepatitis (MASH). These conditions, particularly in individuals with obesity, are linked to increased mortality and are recognized by the Lancet Commission as serious health complications stemming from obesity.

We’ve updated our enhanced anti-obesity policy to refine eligibility for GLP-1 medication coverage and identified specific high-risk clinical manifestations of obesity that now allow for coverage under certain conditions.

Now, members with a BMI of at least 40 who have one of the following three high-risk conditions may be eligible for coverage:

Moderate to severe obstructive sleep apnea
Coronary artery disease, previous heart attack or stroke, or peripheral vascular or arterial disease
Moderate to advanced metabolic-dysfunction associated steatohepatitis (MASH)

Please use this chart as a reference to GLP coverage and medical policy by market and segment.

REMINDER: Transitioning to Biosimilar Drugs

Highmark is changing how certain prescription drugs are covered. Beginning January 1, 2026, Commercial and Healthcare Reform formularies will no longer cover Humira and Stelara as preferred prescription drugs. Instead, we will be covering biosimilar drugs, which are very similar to the original brand name drugs in terms of safety and effectiveness. (This change will also include Stelara when administered through a medical benefit.)

The preferred biosimilar drug for Humira is Simlandi.
The preferred biosimilar drug for Stelara is Yesintek.

Full details of the program, including applicable market segment, can be found in the initial producer blast by clicking here or visiting the Producer Pulse.

REMINDER: SensibleRx Enhancement and Expansion

In order to maximize the advantages that generic drugs can bring, the SensibleRx program is being enhanced and expanded, effective January 1, 2026 and upon client renewal thereafter.

Enhancements
The enhancement allows the program to bypass certain drugs lists. This means, the penalty won’t apply to the following categories of drugs:

Narrow Therapeutic Index (NTI) drugs that are on an NTI list. These medications require therapeutic drug levels and monitoring for consistent clinical effect. Example drugs include Synthroid and Coumadin.
Affordable Care Act (ACA) Preventive Drugs
The self-administered oncology drug list

Expansion
The expansion applies SensibleRx Complete to a broader scope of membership.

Large Group Fully Insured
Large Group Student Health Insurance Plan (SHIP)
Small Group Grandmothered
Small Group ACA
Individual ACA (standard and non-standard plans)

For additional detail, please click here for a copy of the original producer blast or visit the Producer Pulse.

REMINDER: Price Assure

Effective January 1, 2026, most large group, self-insured clients* in New York, Pennsylvania, and National Markets will automatically be enrolled in Price Assure.

Complete details can be found here or within the Producer Pulse.

UPDATE: Prescription Drug Management Updates

Highmark is committed to ensuring our members have access to safe, effective, and cost-efficient treatment options, including prescription drugs. As part of our ongoing review of current research and commitment to clinical excellence we are implementing changes to how we cover select medications. These changes will impact members with Commercial and Healthcare Reform coverage, effective January 1, 2026. These enhancements involve certain medications becoming subject to either Step Therapy requirements or being added to Highmark’s Market Watch Program.

Prescription Drug Management Updates (Blue Cross Blue Shield)
Prescription Drug Management Updates (Blue Shield)
Formulary Deletions (Blue Cross Blue Shield)
Formulary Deletions (Blue Shield)

What do I need to do?

Inform your clients about these important pharmacy programs and resources that are available to their employees.

Where do I go with questions?

Please contact your Sales Executive or Client Manager with any additional questions.

Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association:
Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company.
Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.
PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418.
Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.
West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Visit https://www.highmarkbcbswv.com/networkaccessplan to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card.
Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield.
Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
Highmark Blue Cross Blue Shield and Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

This email was sent by: Highmark, Inc.-
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