Pharmacy Benefits Program

This page gives you a brief overview of Highmark Delaware's Pharmacy Benefits Program and information on the following topics:

General Information about Pharmacy Benefits

Pharmacy Benefits for Managed Care Members

Highmark Blue Cross Blue Shield Delaware administers prescription benefits for almost all members. For those members, the Express Scripts logo appears on the member's ID card.

Mandatory Generic Feature

Many plans include a mandatory generic provision. A mandatory generic provision requires the member to use a generic version of a drug if available. A generic provision can be either "soft" or "hard". If the generic provision is "soft", the member will only be required to pay a brand copay if the physician specifically documents that the brand is medically necessary. If the physician does not specifically document this, the member will be responsible for the difference in cost between the brand and generic plus the generic copay. If the generic provision is "hard", the member will be responsible for the difference in cost between the brand and generic plus the generic copay, even if the physician documents that the brand is medically necessary.

When allowed by a member's pharmacy benefit, the prescribing physician may use the standard medication request form along with pertinent medical record documentation related to the need for BRAND name medication for generic substitution.

View our Generic Substitution Policy

Pharmacy Networks

The Premier Delaware network includes approximately 61,000 chain and independent pharmacies nationally. Pharmacies have point-of-sale technology that confirms a member's eligibility, benefit design and copayment information at the time of dispensing. Members can visit the Highmark Blue Cross Blue Shield Delaware web site, or call Member Services at the number shown on their ID cards to find a network pharmacy that is conveniently located.


The Formulary

The Drug Formulary is a list of FDA-approved prescription drug medications reviewed by our Pharmacy and Therapeutics (P&T) Committee. This committee is comprised of network physicians and pharmacists who select products on the basis of their safety, efficacy, quality and cost to the plan.

The formulary is designed to assist in maintaining the quality of patient care and containing cost for the patient's drug benefit plan. The P&T Committee approves revisions to the drug formulary on a quarterly basis; updates will be provided to reflect such additions.

Products are removed from the formulary twice a year, January 1st and July 1st, after a minimum of 30 days notification is given to providers. To obtain a copy of the formulary, contact your Provider Relations representative.

Physicians are requested to prescribe medications included in the formulary whenever possible.

Clinical PharmacyServices monitors provider-specific formulary prescribing and communicates with providers to encourage use of formulary products.

The drug formulary is then divided into major therapeutic categories for easy use. Products that are approved for more than one therapeutic indication may be included in more than one category. Drugs are listed by brand and generic names. Most dosage forms and strengths of a drug are included in the formulary.

View the Formulary


Home Delivery / Mail Order Service

Home delivery service is an option that groups may select depending on their benefit design. Members may call the Member Services telephone number on their identification card to find out if they have home delivery coverage.

Advantages of Using the Mail Order Service
Mail order is an option that the majority of groups select. This service enables members to obtain up to a 90-day supply of either generic or brand name drugs, for the specific mail order cost-share that the group has selected. Members enjoy the convenience of convenience and potential cost savings.

How to Assist Members in Using the Mail Order Service
If a member must begin taking a new maintenance drug immediately, they may need to have two prescriptions. The member can have one of the prescriptions filled at a local pharmacy to begin taking the medication immediately. (It is recommended that this prescription be written for a two-week supply.) The member can send the other prescription to the mail order service for up to a 90-day supply.

How Members Use the Mail Order Service
Members can obtain mail order forms for maintenance drugs by calling the Member Service telephone number on their ID card. Once a member places an order, the member's information remains on file. Any subsequent refills do not require an order form. For refills, the member can call the toll-free number, send in the refill form with the applicable co-payment, or visit the Highmark Blue Cross Blue Shield Delaware web site.

Last updated on 4/19/2017

 

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