Volume 17 • Issue 10 • october 2015 Newsletter Excerpt

In the past, many patients found they could not tolerate these drugs and, therefore, many dosages were not used. This program greatly reduces the amount of unused dosages of these medications, some of which can cost thousands of dollars per month.

Please Note:• ThesedrugswillNOTbecoverediftheyareobtainedataretailpharmacyor viamailorderservice.

• ThisprogramcanbeusedbyallHighmarkmembers.However,duetoMedicarePartDprescriptiondrugcoverageregulations,itisNOTmandatoryforMedicareAdvantagepatients.PatientsthatareenrolledinHighmarkMedicareAdvantageplansmaycontinuetoobtainthesedrugsataretailpharmacyorthroughmailorderservice.MedicareAdvantagememberscanalsoelecttoobtaintheirspecialty drugs through Walgreens Specialty Pharmacy.

Asalways,memberbenefitsdovary.Providersshouldcontinuetoverifyallmembers’benefitspriortoserviceviatheEligibility and Benefits Inquiry functiononNaviNet.

Simplified Precertification ProcessThere are no changes to medical policy or procedures connected with this program.Highmarkmemberswhosebenefitdesignscurrentlyrequirepriorauthorizationforthedrugscontainedonthelistwillcontinuetorequirepriorauthorization.Providersareresponsibleforobtainingpriorauthorizationfor their patients.

To initiate the precertification process and order these drugs for your patients, youneedonlymakeonecalltoWSP at 1-888-347-3416.Thisprocesssavesyoutimeandhelpsyourpatientsreceivetheirmedicationspromptlyanddirectlyattheir homes.

ProviderscanalsousetheNaviNetAuthorization Submission transaction for prescriptiondrugauthorizations.Thistransactioncanbeusedforanypharmacyauthorizationrequests,includingnon-formularyexceptionrequests,priorauthorizationsorManagedRxCoverage(MRxC)programs.

Thecurrentlistofdrugs(asofSept.21,2015)thatareincludedintheprogram isincludedhereforyourconvenience:Retail Exclusivity Drug List. You can also find this information under Pharmacy/FormularyonHighmark’s Provider Resource Center. Go to Pharmacy/Formulary Information, and then select Program for Self-Administered Injectable or Oral Biotechnology Drugs.

Ifyouhavequestionsaboutthisprogramorthedrugsincludedonthecurrent list of drugs, please call Provider Service at 1-866-262-5635.

New Service Begins Jan. 1, 2016 Highmarkcontinuestoexpandontheservicesprovidedtoprofessionalproviders.Inconjunctionwithourcommitmenttoqualityandcostcontainment, we are introducing a newprogramforSelf-AdministeredInjectableandOralBiotechnologySpecialty Drugs.

BeginningJan.1,2016,yourpatientswhoarecurrentlyenrolledinHighmarkhealthplansANDthosewhohavetransitionedfromBCNEPA’sFirstPriorityHealthandFirstPriorityLifeInsuranceCompanyhealthplanstoHighmarkhealthplanswillneedtoobtainthespecialty drugs they use exclusively from Walgreens Specialty Pharmacy (WSP). This program will also apply to newHighmarkhealthplansasthey are introduced.

Program BenefitsTheSelf-AdministeredInjectableandOralBiotechnologySpecialtyDrugprogramisdesignedto:

• Enhanceintegratedcareandutilization management for patients who use these drugs

• Ensurethedrugsareadministered in the most appropriate and effectivemanner

• Simplifytheprecertificationprocessfor these medications

• Reducecostsbyminimizingwaste

Self-Administered Injectable and Oral Biotechnology Drugs