Provider Resource Center

[{"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\u003eStarting in December, the Highmark Wholecare Provider Newsletter is being 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\u003eProviders will have access to a new Clinical Platform, GuidingCare, starting January 1, 2024. This platform will allow access to an Authorization Portal via NaviNet. To learn more about accessing this new platform, please review the provider guide found \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/docs/GuidingCareUserGuide.pdf\"\u003ehere\u003c/a\u003e.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":260,"versionId":5,"title":"Mediciad Redetermination","type":4,"subType":null,"childSubType":"","date":"8/14/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eThere are members who may still be eligible for Medicaid but are being disenrolled due to failure to renew or provide the required documentation. To assist with identifying affected patients, please view the expanded PCP Medical Assistance (MA) Renewal Report in our provider portal, via NaviNet. Additionally, this flyer (\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/docs/MX2310022_Medicaid_FLY_FS-BS.pdf\"\u003eEnglish\u003c/a\u003e, \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/MXS2310022_SPA_Medicaid_FLY_BS_FS.pdf\"\u003eSpanish\u003c/a\u003e) can help patients who have been disenrolled from Highmark Wholecare Medicaid coverage.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":261,"versionId":5,"title":"Model of Care Reminder for Medicare providers","type":4,"subType":null,"childSubType":"","date":"8/14/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eAs a Special Needs Plan (SNP), Highmark Wholecare is required to administer a Model of Care Plan (MOC) that will allow our Medicare Advantage Organization to provide coordinated care for special needs individuals. Highmark Wholecare expects all network practicing providers to receive MOC training annually. To access the full training document and sign your attestation, click \u003ca href=\"https://wholecare.highmarkprc.com/Medicare-Resources/Model-of-Care\"\u003ehere\u003c/a\u003e.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}]

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[{"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/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\u003c/ul\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":20,"versionId":42,"chapterNumber":8,"title":"Free Market Health (FMH)","visible":false,"topics":[{"id":49,"chapterId":20,"unitNumber":8,"timestamp":"1/1/0001","title":"Free Market Health (FMH)","description":"\u003cp\u003eFree Market Health (FMH) is a healthcare technology company that orchestrates and optimizes the specialty drug fulfillment process. In April of 2021, Highmark Wholecare collaborated with FMH to launch an innovative specialty pharmacy program for select specialty medications. The program facilitates a match process that gets a specialty prescription to the in-network specialty pharmacy best-suited to service that member.\u003c/p\u003e\n\u003cp\u003eSpecialty medications included in the Free Market Health program are indicated as Specialty Pharmacy Group A (or SPA) on the\u003cspan\u003e\u0026nbsp;\u003c/span\u003e\u003ca href=\"https://highmark.com/wholecare/medicaid/coverage-benefits/medication-information-center/specialty-pharmacy\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eSpecialty Drug List\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhy are we collaborating with Free Market Health?\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eTo increase process efficiency, improve care quality, and decrease the time it takes for members to receive their medications.\u003c/li\u003e\n\u003cli\u003eTo offer transparent and fair access to authorized referrals to our specialty pharmacy network and reward high-quality care.\u003c/li\u003e\n\u003cli\u003eTo leverage dynamic drug rates and ensure specialty drugs remain affordable for our members.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHow does the program work?\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eUpon an approved prior authorization for select specialty drugs, FMH receives the referral for management.\u003c/li\u003e\n\u003cli\u003eFMH orchestrates Highmark Wholecare\u0026rsquo;s program configuration and evaluates the referral based on drug, disease, member, and plan attributes.\u003c/li\u003e\n\u003cli\u003eThe referral, inclusive of care accountabilities and incentives, is matched to an in-network specialty pharmacy best-suited to service the referral.\u003c/li\u003e\n\u003cli\u003eThe assigned specialty pharmacy will reach out to the prescriber to obtain the prescription and onboard the member to initiate service.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHow does this impact prescribers?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prior auth process is not changing, and prescribers should continue to submit prior authorizations as usual.\u003c/p\u003e\n\u003cp\u003eBecause any in-network specialty pharmacy may service Highmark Wholecare members, prescribers and their patients may notice new specialty pharmacies dispensing their medication(s). The specialty pharmacy authorized by Highmark Wholecare to service a specialty referral will coordinate with the prescriber office to obtain the prescription. Highmark Wholecare works closely with network pharmacies to maintain strict controls for quality.\u003cbr /\u003eMember preference for a specialty pharmacy will be honored if the pharmacy remains in network and can supply the specialty medication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow does this impact members?\u003c/strong\u003e\u003cbr /\u003eThe specialty drug process under FMH is managed and streamlined to decrease the time it takes for members to receive their medications, monitor first fills, and reduce medication abandonment for members in need of and authorized for a specialty drug. Members are also serviced by a specialty pharmacy capable and accountable to meet their needs with focused care management that improves the patient experience.\u003c/p\u003e\n\u003cp\u003eMember preference for a specialty pharmacy will be honored if the pharmacy remains in network and can supply the specialty medication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrescribers or specialty pharmacies wanting more information on the Free Market Health program or in need of assistance can contact the FMH team at 877-787-0520.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFree Market Health, a separate healthcare technology company, provides end-to-end specialty drug process optimization for Highmark Wholecare members.\u003c/em\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2}]

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Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. 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.

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