Provider Resource Center

[{"id":409,"versionId":5,"title":"Annual Provider Training","type":4,"subType":null,"childSubType":"","date":"5/1/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eHighmark Wholecare invites providers to attend the 2024 Provider Education and Orientation Training to learn about topics such as EPSDT, access/accessibility surveys, Fraud, Waste, and Abuse, Model of care, self-service tools, Cultural Competency, claims, and more! The training is on-demand and can be viewed at your convenience. Register \u003cstrong\u003e\u003ca href=\"https://www.brainshark.com/1/player/highmarkmedicaid?pi=zKFzuRilozibduz0\u0026amp;r3f1=18225c0f030e5644145e224717161e0d195e0722411c1b100d195059384b5510120144\u0026amp;fb=0\"\u003ehere.\u003c/a\u003e\u003c/strong\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":392,"versionId":5,"title":"UM Transitions","type":4,"subType":null,"childSubType":"","date":"3/26/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003eImportant UM Authorization Updates:\u003c/strong\u003e\u0026nbsp;Effective May 1st, there\u0026nbsp;are updates to the authorization requirements and processes for various Highmark Wholecare services. To learn more about these specific changes and to review reference materials, visit the following links:\u003cstrong\u003e \u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/391/New-Authorization-Requirements-for-Musculoskeletal-Pain-Management-Diagnostic-Imaging-and-Physical-Medicine\"\u003eMusculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/390/New-Authorization-Process-for-Family-Planning\"\u003eFamily Planning\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u0026nbsp;\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/389/New-Authorization-Requirements-for-Cardiology\"\u003eCardiology\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":383,"versionId":5,"title":"Change Healthcare Cyber Incident Banner","type":4,"subType":null,"childSubType":"","date":"3/19/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eImportant Provider Notice - March 5, 2024 - Change Healthcare Event: Highmark Wholecare Claims/Remittance Update\u0026nbsp;-\u0026nbsp;\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/BS_Wholecare%20Provider%20Notification%20Change%20Healthcare%20Update%20FINAL%203.5.24%20245pm.pdf\"\u003ePlease click here for more information.\u003c/a\u003e\u0026nbsp;Additionally, to learn more about how Highmark Wholecare is assisting providers impacted by the Change Healthcare cyber event, click \u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/382/Assistance-for-Highmark-Wholecare-Participating-Providers-Impacted-by-Change-Healthcare-Cyber-Event\"\u003ehere.\u003c/a\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":289,"versionId":5,"title":"E-Subscribe Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"12/6/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eThe Highmark Wholecare Provider Newsletter has been replaced with the \u003cstrong\u003e\u003cem\u003eProvider News\u003c/em\u003e monthly email\u003c/strong\u003e. The \u003cem\u003eProvider News\u003c/em\u003e email will become our primary communications channel, allowing us to consolidate and simplify updates for you each month. \u003ca href=\"https://wholecare.highmarkprc.com/e-Subscribe-for-Publications-and-Notifications\"\u003eSubscribe here\u003c/a\u003e to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and more!\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":287,"versionId":5,"title":"GuidingCare Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"11/30/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp style=\"margin: 0in;\"\u003eProviders now have access to a new Clinical Platform, GuidingCare. This platform allows access to an Authorization Portal via NaviNet. Please utilize this online capability as the preferred method to submit your authorization requests. To learn more about accessing this new platform, please review the provider guide \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/docs/GuidingCareUserGuide.pdf\"\u003ehere\u003c/a\u003e.\u003co:p\u003e\u003c/o:p\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}]

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Medicaid Drug List & Medication Policies

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MEDICATION POLICIES

[{"id":7,"versionId":42,"chapterNumber":1,"title":"Highmark Wholecare Family Planning Services","visible":false,"topics":[{"id":26,"chapterId":7,"unitNumber":1,"timestamp":"1/1/0001","title":"Family Planning Services","description":"\u003cp\u003eHighmark Wholecare covers family planning services. These services include:\u003c/p\u003e\n\u003cp\u003e■ Pregnancy testing\u003c/p\u003e\n\u003cp\u003e■ Testing and treatment of sexually transmitted diseases\u003c/p\u003e\n\u003cp\u003e■ Birth control supplies, including up to a 12-month supply of oral contraceptives\u003c/p\u003e\n\u003cp\u003e■ Family planning education and counseling\u003c/p\u003e\n\u003cp\u003eIn April 2014, the Office of Population Affairs (OPA) and the Centers for Disease Control and Prevention (CDC) issued the report, Providing Quality Family Planning Services (QFP), which further supports the need for these services.\u003c/p\u003e\n\u003cp\u003eHighmark Wholecare encourages prescribers of contraceptives to provide information about all family planning options available to women. The printout below can be shared with Highmark Wholecare Members on all family planning options.\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Docs/FamilyPlanningInfoMembers.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eInformation about Family Planning Services For Members\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":8,"versionId":42,"chapterNumber":2,"title":"Medical Assistance (Medicaid) 90 Day Generic Medication Supply","visible":false,"topics":[{"id":30,"chapterId":8,"unitNumber":2,"timestamp":"1/1/0001","title":"Medical Assistance (Medicaid) 90 Day Generic Medication Supply","description":"\u003cp\u003eHighmark Wholecare offers a 90 day supply of select generic medications for diabetes, asthma, cholesterol, blood pressure, mental health, and more. Save money on co-pays and make less trips to the pharmacy!\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=l98XlMfAqkaSnQhW-Qo0Pg\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eView the complete list of medications covered for 90 days.\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":9,"versionId":42,"chapterNumber":3,"title":"Medical Assistance (Medicaid) Providers Formulary Medication Coverage","visible":false,"topics":[{"id":31,"chapterId":9,"unitNumber":0,"timestamp":"1/1/0001","title":"Medicaid Formulary Medication Information","description":"\u003cp\u003e\u003ca href=\"https://secure-web.cisco.com/1OhoiLa6bAVkVaMfuAqK8yVyZJ71YsAX57lxEfAxNzFrSvEDGcGrLtFctTKkLhkJ0WbIl811ccr6zf9hwMyY9Hbnwbow4mDyAeun6fgwuK3wXzaoVXm2us7BkDQ5DUPqM9MrrbYkUze8Z6-pOnwCxN_Idrky8u-uEl6Ab41KALfxlxWz_PZLhEQKkb86AjHdm9z-020gXUAjBnL0SRWrKMwM7kLRoDAELSVDeM7swC65cXUhmksNZE_7wEdjlkvGr6_0Cl7yTMeQ5m_CrBknE6D-UjaiWznHeOcU2y6OQE2dnexsSmrdx5_nrENR0VKu9/https%3A%2F%2Fclient.formularynavigator.com%2FSearch.aspx%3FsiteCode%3D9766213130\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eVisit our Formulary Medications page for more information.\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":10,"versionId":42,"chapterNumber":4,"title":"Opioid Information","visible":false,"topics":[{"id":36,"chapterId":10,"unitNumber":4,"timestamp":"1/1/0001","title":"Opioid Information","description":"\u003cul\u003e\n\u003cli\u003e\u003ca href=\"https://www.cdc.gov/drugoverdose/prescribing/clinical-tools.html\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eOpioid\u0026nbsp;- CDC Guideline for Prescribing\u0026nbsp;Opioids\u0026nbsp;for Chronic Pain\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.dhs.pa.gov/Services/Assistance/Pages/Centers-of-Excellence.aspx\" target=\"_blank\" rel=\"noopener noreferrer\"\u003ePA Opioid Use Disorders Centers of Excellence\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.solvethecrisis.org/\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eSurgical and Dental Opioid Prescribing Guidelines\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":17,"versionId":42,"chapterNumber":5,"title":"Pharmacy \u0026 Therapeutics (\"P\u0026T\") Committee Meeting Minutes","visible":false,"topics":[{"id":46,"chapterId":17,"unitNumber":5,"timestamp":"1/1/0001","title":"Pharmacy \u0026 Therapeutics (\"P\u0026T\") Committee Meeting Minutes","description":"\u003cp\u003eThe minutes of the Highmark Wholecare P \u0026amp; T Committee have participants\u0026rsquo; names redacted.\u0026nbsp; No actions taken by the P \u0026amp; T Committee constitute formulary changes unless and until approved by the Department of Human Services (DHS).\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/PT Minutes_November 2023_PA Medicaid_Redacted.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eNovember 23\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/PT Minutes_August 2023_PA Medicaid redacted.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eAugust 23\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/May23.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eMay 23\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/Feb23.pdf\"\u003eFeb 23\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/Nov22.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eNov\u0026nbsp;22\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/Aug22.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eAug 22\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/May22.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eMay 22\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/Feb22.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eFeb 22\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/ptm/Nov21.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eNov 21\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":18,"versionId":42,"chapterNumber":6,"title":"Prescription Drugs Monitoring Program Education","visible":false,"topics":[{"id":47,"chapterId":18,"unitNumber":6,"timestamp":"1/1/0001","title":"Prescription Drugs Monitoring Program Education","description":"\u003cp\u003e\u003cstrong\u003e\u003ca href=\"https://www.health.pa.gov/topics/programs/PDMP/Pages/Education.aspx\" target=\"_blank\" rel=\"noopener noreferrer\"\u003ePrescription Drugs Monitoring Program Education\u003c/a\u003e\u003c/strong\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":19,"versionId":42,"chapterNumber":7,"title":"Medical Assistance (Medicaid) Specialty Pharmacy","visible":false,"topics":[{"id":48,"chapterId":19,"unitNumber":7,"timestamp":"1/1/0001","title":"Medical Assistance (Medicaid) Specialty Pharmacy","description":"\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003ca href=\"https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=cVyVzMn_lUuDLcryCI4Iwg\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eSpecialty Pharmacy Provider List\u003c/a\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003e\u003ca href=\"https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=4-_UuGqOukS4fnXGJ1Ljfw\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eSpecialty Pharmacy Drug List\u003c/a\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eHighmark Wholecare\u0026nbsp;works with Free Market Health to support our specialty pharmacy program through their platform, by aligning members with a best fit, in-network specialty pharmacy, while preserving member choice and continuity of care. \u0026nbsp;\u003cstrong\u003ePlease note: From time to time, you may receive a request to transfer a prescription to a new specialty pharmacy as a result of this process.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2}]

Revision Date

The following entities, which serve the noted regions, 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. 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. 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.

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.

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