Medication Formulary and Exceptions

When you need to use your D-SNP medication benefits, it’s important to know about your Drug List and what to do if your prescription drug isn’t covered.

Using Your D-SNP Formulary

Your Highmark Wholecare D-SNP Formulary, also known as Drug List, shows you every covered drug under your prescription drug benefits. All drugs approved for coverage are:

• Reviewed and recommended by Highmark Wholecare's P&T Committee
• Chosen based on safety, efficacy, quality and cost
• Food and Drug Administration (FDA) approved 

Your Drug List also groups covered drugs by type and cost, also known as tiers. If a Medicare covered medication is not in the Drug List, it’s usually not covered by your D-SNP.

You can quickly and easily search the Diamond and Ruby D-SNP Drug List.

2025 Drug List

2024 Drug List

Learning About Prescription Transition Policy

If your drug is not on the Drug List or is restricted, here are some things you can do to help avoid missing doses.

Get a Temporary Supply

In some cases, your D-SNP can offer you a temporary drug supply if your drug isn’t on the Drug List or if it’s restricted. This can give you and your doctor time to review other options or ask for a medication exception.

To be considered for a temporary supply, some rules must be met, like:

• The drug you’ve been taking is no longer on your D-SNP Drug List.
• The drug you’ve been taking is restricted in some way.
• As a new or continuing D-SNP member, you may be taking drugs that are not on our formulary.
• You may be taking a drug that is on your D-SNP Drug List but your ability to get it is limited.

As an example, you may need a prior authorization from us before you can fill your prescription. If this happens, you should talk to your doctor to decide if you should consider a covered drug or request a formulary exception so that the drug you take gets covered.

Temporary Coverage During First 90-Days

In some cases, your drug may get covered during your first 90 days as a Highmark Wholecare D-SNP member.

As examples, the following members can get a temporary supply of each drug that’s not on our formulary or if the ability to get your drugs is limited.

If You Were a D-SNP Member Last Year and Aren’t In a Long-Term Care Facility

For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of the calendar year if your claims history shows you were previously on the drug and Highmark Wholecare made formulary changes from the previous year that negatively impacted you. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of the calendar year.

If You’re a New D-SNP Member and Aren’t In a Long-Term Care Facility

For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.

If You’re a New D-SNP Member and Live In a Long-Term Care Facility

For one time only, your D-SNP will cover a supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 31 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 31 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.

If You’ve Been a D-SNP Member For More Than 90 Days, Live In a Long-Term Care Facility and Need a Supply Right Away

Your D-SNP will cover one 31-day supply, or less if your prescription is written for fewer days while an exception or prior authorization is requested. This is in addition to the above long-term care transition supply.

Change to Another Drug

If your drug isn’t on your D-SNP Drug List or is restricted, you can change to another drug.

You can call Member Services at 1-800-392-1147 (TTY 711) to ask for a list of covered drugs that treat the same medical condition. Sharing this list with your doctor can help you both decide if you should make medication changes.

Request an Exception

You and your doctor can request an exception by asking Highmark Wholecare to cover the drug or remove restrictions from the drug. If your doctor agrees that you have medical reasons that justify asking for an exception, he or she can help you make the request.

Asking For Medication Exceptions

If your medication isn’t covered under your D-SNP prescription drug benefits, you can ask Highmark Wholecare Medicare Assured to make a coverage rule exception.

Exception Request Examples

When you need to request a medication exception, you can ask your D-SNP to:

• Cover your drug even if it isn’t on our formulary.
• Waive coverage restrictions or limits on your drug. For example, for certain drugs, Highmark Wholecare Medicare Assured limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
• Cover your drug at a lower cost-sharing tier if your drug is in a cost-sharing tier you think is too high. Note, we don’t lower the cost-sharing amount for drugs in the Specialty tier.

When you are requesting a formulary or utilization restriction exception you must submit a statement from your doctor supporting your request. Your prescribing doctor or professional can either call Highmark Wholecare or complete the Medicare Request for Drug Coverage Form

Requesting Exceptions with CoverMyMeds

CoverMyMeds is a platform that helps patients get the medication they need to live healthy lives by streamlining the prior authorization (PA) process for providers and pharmacists.

CoverMyMeds Online Request:

You can visit the CoverMyMeds website to create a free account or log in to your existing account before completing your request.

CoverMyMeds Request By Mail:

You can mail your request to:

Highmark Wholecare Medicare Assured
P.O. Box 22158
Pittsburgh, PA 15222-1222

CoverMyMeds Request By Fax:

You can fax your request to 1-888-447-4369.

Note, if you’re sending in your own request, your prescribing doctor or professional must send a statement to support your request for coverage determination. The statement should also detail if your health could be seriously harmed by waiting three days for a request decision.

Highmark Wholecare Decisions

You should contact us to ask us for an initial coverage decision on your formulary or utilization restriction exception. Generally, we must make our decision within 72 hours of getting your doctor’s supporting statement.

In most cases, Highmark Wholecare will only approve your request for an exception if the alternative drugs included on your D-SNP formulary or additional utilization restrictions aren’t as effective in treating your condition and/or would cause adverse medical effects.

Requesting Reconsideration after Denial

If your request for exception is denied, you have the right to request Reconsideration (redetermination) for this decision.

Request By Phone:

If you’re a Pennsylvania resident, you can call:

1-800-685-5209 (TTY 711)

8 a.m. – 8 p.m. ET
October 1 - March 31: 7 days a week
April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday

Request By Mail:

You can complete the Request for Redetermination Formand mail it to:

Highmark Wholecare
Attention: Appeals & Grievances
P.O. Box 22278
Pittsburgh, PA 15222

Note, your doctor may make this request for you. You can also hand-deliver your Redetermination Form if preferred. Note, if someone is filing a request on your behalf, you must include a completed Highmark Wholecare Medicare Assured Appointment of Representative Formto give this person permission.

Request By Fax:

You can fax your Request for Redetermination Formto us at 412-255-4503.

Help With Formulary and Exemptions Questions

If you have questions on how your medication formulary or exemptions work, please review your EOC. You can also call Member Services at 1-800-392-1147 (TTY 711).