Guide to drug coverage under medical benefit
Prescription drugs are covered in two ways—through the Highmark BCBSWNY pharmacy benefit or via medical benefit. The method of coverage depends on whether the drug is self-administered or administered by a health care professional at home (ex. home infusion therapy) or given in a clinical setting like a doctor’s office.
Drugs that are only administered to members by healthcare professionals are available under the medical benefit and can be obtained in several ways:
- Buy and Bill: Physicians may purchase drugs directly through pharmaceutical wholesalers and distributors and submit a claim to Highmark BCBSWNY. To review the list of services and drugs that are billable on the medical benefit for Highmark BCBSWNY please refer to the State Fee Schedule
- Delivery: Physicians may request delivery of a member-specific specialty medication that will be administered in his or her office, by calling Highmark BCBSWNY contracted Medical Specialty Pharmacy (MSP), CVS Specialty®
- Referral: Physicians may refer their members to infusion suites and outpatient hospital services
Note: CVS Specialty® is an independent company providing pharmacy services on behalf of Highmark.
For more information on self-administered prescription drugs and pharmacy benefit coverage please visit the Highmark BCBSWNY pharmacy page.
Drug Clinical Criteria
CarelonRx
CarelonRx is an independent company providing pharmacy benefit management services on behalf of the plan. Clinical Criteria for drugs and biologics paid under the medical benefit for certain Medicaid markets can be found on the CarelonRx website.
State specific custom medical criteria
The state specific custom medical criteria for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit are here.
All other medical criteria
The Clinical Criteria for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit are available for certain Medicaid markets.
Medical Specialty Pharmacy (MSP)
Highmark BCBSWNY is pleased to announce a drug delivery option that enhances medication accessibility to both members and providers. Highmark BCBSWNY is contracted with CVS Specialty® as the MSP. CVS Specialty® can deliver member specific medication that is covered under the Highmark BCBSWNY medical benefit to your office for administration to the member.
Delivery of medication
To set up delivery or check a prescription order status please call 877-254-0015 and you will be transferred to a pharmacist for a verbal prescription order. Please plan to provide your member's Highmark BCBSWNY ID located on their ID card. Staff will obtain additional information necessary to support the delivery of the medication, including the need by date. Please allow up to 10 days for processing and shipping. The staff will then make an outbound call to your member to obtain consent as needed to support the delivery of the medication to your office. Once all necessary information is obtained for shipping, the staff will make an outbound call to your office to confirm delivery.
You may also fax prescription orders to 866-336-8479, and a staff member will call your office to obtain additional information necessary to support the delivery of the medication as described above.
Note: If it is an urgent medication request and the need by date is less than 7 days from the order date, please indicate this, so the order can be expedited.
Prior authorization
Some medications require precertification before they can be paid. Please review the precertification lookup tool for a listing of covered drugs and any associated requirements. If prior authorization is required, you may request precertification by phone, fax, or electronically.
How to request prior authorization
To ensure timely review of the prior authorization request, please include the servicing medical specialty pharmacy and provider name during the prior authorization intake.
Request by phone
Phone: 866-231-0847
Monday – Friday, 8:00 am – 7:00 pm EST; Saturday, 10:00 am – 2:00 pm EST
Request by fax
Medical injectables: 844-493-9206
Request electronically
Electronic prior authorizations (ePA)
Electronic prior authorization requests can be submitted through CoverMyMeds, an independent company providing medication precertification services on behalf of Highmark BCBSWNY.
Using CoverMyMeds for prior authorization requests
CoverMyMeds streamlines the medication precertification process, electronically connecting providers, pharmacists, and plan/Pharmacy Benefit Managers (PBMs) to improve time to therapy and decrease prescription abandonment with electronic prior authorization.
Prescribers can view real-time status of any medication precertification request submitted via ePA, phone, or fax by logging into the CoverMyMeds website and entering the member’s information. Prescribers also have the option to contact CoverMyMeds directly by calling 866-452-5017 for questions, information, or website concerns, or via live chat on the CoverMyMeds website.
Home infusion therapy (HIT)
Home infusion therapy is the administration of prescription legend drugs through intravenous, intraspinal, epidural, or subcutaneous routes from the comfort of the member’s home. HIT is prescribed by a physician that both the physician and Highmark BCBSWNY have determined to be medically necessary and must supervised by a qualified health care professional to the member in their residence.
To find an in-network HIT provider please use our Find a pharmacy tool.
Prior Authorization Lookup Tool
To request or check the status of a prior authorization request or decision, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
Additional resources
Provider tools and resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Precertification lookup tool
- Precertification requirements
- Claims overview
- Member eligibility & pharmacy overview
- Provider manual and guides
- Referrals
- Forms
- Training Academy
- Pharmacy information
- Electronic Data Interchange (EDI)