Prescription Drug Program administered by Highmark Blue Shield.

Prescription Coverage Summary

Prescription Drug Tier Retail Copay (30-day supply) Mail-Order Copay (90-day supply)
Generic $10 $20
Brand Drugs, Formulary $30 $60
Brand Drugs, Nonforumulary $50 $100

 
Certain prescription drugs are subject to prior authorization requirements, quantity level limits, or other management programs to ensure that these medications are being used in a safe and effective manner, and to help both you and the health plan control costs. If you are taking a prescription drug in one of these drug classes, you may receive a letter from Highmark advising you of any additional requirements with which you or your medical provider may need to comply.
 

Managed Rx Coverage Program

The managed prescription drug coverage (MRxC) program consists of online edits that encourage the safe and effective use of targeted medications to meet the clinical needs of members. To better manage the rising cost of these medications, the MRxC program also promotes the use of lower cost brand and generic medications. Many of the criteria are automated in order to reduce the administrative burden on physicians and to reduce member disruption.  
 

Managed Prior Authorization Program

Certain medications will require prior authorization to ensure the medical necessity and appropriateness of the prescription order as defined by Highmark prior authorization policies. The member’s prescriber must obtain authorization from the Plan, prior to dispensing the medication by a retail pharmacy or through mail order, if applicable, otherwise the medication will not be covered by the Plan.
 

Step Edit Program

Generic medications can reduce prescription cost, and increase medication adherence while providing the same benefits as the brand name medication. This policy defines the criteria under which coverage for a brand name medication will be considered when generic products are available within the same therapeutic class. Medications targeted in program are used to treat acid reflux, cholesterol, and depression.
 

Specialty Medication information

If you or a covered family member need(s) to take a specialty medication, you will need to obtain the prescription from Accredo, a mail-order pharmacy provider solely focused on specialty medications.
Accredo has negotiated with Highmark to provide the deepest discounts on specialty medications, which can average $5,000 or more in cost per month. For questions or concerns, contact Accredo at 1-888-692-8110.

What is a specialty medication?
Specialty medications are used to treat chronic, rare, or complex conditions (such as rheumatoid arthritis, multiple sclerosis, or cancer). Additionally, specialty medications may:
  - Be given by infusion, injection, or taken orally.
  - Cost more than traditional medications.
  - Have special storage and handling requirements.
  - Need to be taken on a very strict schedule.
  - Have support programs and services available to help patients receive the most benefit from their medication