Important updates regarding Highmark formulary changes for January 1, 2025
Highmark Blue Shield has made the decision across its book of business to update the prior approval requirements for several drugs as listed in the chart below. Notification regarding these changes was made to affected members, including covered dependents, via a letter mailed from Highmark in November 2024.
Your prescribing doctor may have also been notified of this change. Please talk with your doctor about your options, such as switching to a covered alternative. If your doctor feels there is a medical reason for you to continue to take your current medication, rather than one of the covered alternatives, your doctor will need to complete the required prior authorization request and send it to Highmark. Please note that in order for Highmark to approve a prior authorization request, the medical information submitted by your doctor must satisfy the medical condition in support of the drug. Highmark will provide you and your doctor the final outcome of the request.
An area of note regarding Continuous Glucose Monitors (CGMs), use of insulin a key criterion for prior approval. If you are an individual using a CGM for treatment of Type-2 Diabetes, but you do not use insulin, you may wish to speak with your doctor about other over the counter (OTC) options, such as the CGM examples below, that are currently available. While these OTC options are not able to be submitted to your medical plan, you may use your Health Savings Account (HSA) or Health Care Flexible Spending Account (FSA) funds to pay for these options.
- Dexcom Stelo: $99 per month subscription (discounted if you have longer subscriptions) for the sensors.
- Abbott Lingo: There are options to get it every 2 weeks, every 4 weeks or every 12 weeks.
Additionally, if you are a member unable to fill a CGM due to the formulary changes by Highmark, the regular, finger-stick glucose monitor brands One Touch, Freestyle (not Libre), and Precision are available, covered alternatives under the plan.
Please discuss any medication questions with your doctor. For questions about your coverage, please call Highmark Member Services at 1-844-945-5509.
| Medications Requiring Prior Approval | Covered Alternatives |
| VYVANSE CAPSULE VYVANSE CHEWABLE TABLET |
LISDEXAMFETAMINE CAPSULE LISDEXAMFETAMINE CHEWABLE TABLET DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE EXTENDED-RELEASE CAPSULE DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULE METHYLPHENIDATE EXTENDED-RELEASE CAPSULE |
| ADDERALL XR CAPSULE ADZENYS XR-ODT TABLET COTEMPLA XR-ODT TABLET DYANAVEL XR SUSPENSION JORNAY PM CAPSULE QUILLICHEW ER CHEW TABLET QUILLIVANT XR SUSP MYDAYIS ER CAPSULE DEXEDRINE SPANSULE |
DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE EXTENDED-RELEASE CAPSULE DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULE METHYLPHENIDATE EXTENDED-RELEASE CAPSULE |
| ZENZEDI 15 MG TABLET ZENZEDI 2.5 MG TABLET ZENZEDI 20 MG TABLET ZENZEDI 30 MG TABLET ZENZEDI 7.5 MG TABLET DESOXYN TABLET METHAMPHETAMINE TABLET |
DEXMETHYLPHENIDATE TABLET DEXTROAMPHETAMINE/AMPHETAMINE TABLET DEXTROAMPHETAMINE TABLET METHYLPHENIDATE TABLET |
| ISTALOL 0.5% EYE DROPS TIMOLOL 0.5% EYE DROP [generic for ISTALOL] |
TIMOLOL MALEATE 0.25% EYE DROP [NON-DROPPERETTE] TIMOLOL MALEATE 0.5% EYE DROP [NON-DROPPERETTE] |
| TIMOPTIC 0.25% OCUDOSE DROP TIMOPTIC 0.5% OCUDOSE DROP TIMOLOL MALEATE 0.25% EYE DROP [DROPPERETTE] TIMOLOL MALEATE 0.5% EYE DROP [DROPPERETTE] |
TIMOLOL MALEATE 0.25% EYE DROP [NON-DROPPERETTE] TIMOLOL MALEATE 0.5% EYE DROP [NON-DROPPERETTE] |
| ALPHAGAN P 0.1% DROPS BRIMONIDINE TARTRATE 0.1% DROP ALPHAGAN P 0.15% EYE DROPS BRIMONIDINE TARTRATE 0.15% DROP |
BRIMONIDINE 0.2% EYE DROP |
| EYSUVIS 0.25% EYE DROPS | OCULAR LUBRICANT |
| BROMFENAC SOD 0.075% EYE DROP BROMFENAC SODIUM 0.07% EYE DRP BROMSITE 0.075% EYE DROPS PROLENSA 0.07% EYE DROPS |
KETOROLAC 0.5% OPHTH SOLUTION DICLOFENAC 0.1% EYE DROPS |
| BRIMONIDINE-TIMOLOL 0.2%-0.5% COMBIGAN 0.2%-0.5% EYE DROPS |
TIMOLOL MALEATE 0.5% EYE DROPS [NON-DROPPERETTE] BRIMONIDINE 0.2% EYE DROP |
| COSOPT EYE DROPS COSOPT PF EYE DROPS DORZOLAMIDE-TIMOLOL 2%-0.5% DORZOLAMIDE-TIMOLOL EYE DROPS |
TIMOLOL MALEATE 0.5% EYE DROP [NON-DROPPERETTE] DORZOLAMIDE 2% EYE DROP |
| EVERSENSE E3 SMART TRANSMITTER EVERSENSE SMART TRANSMITTER FREESTYLE LIBRE 3 READER FREESTYLE LIBRE 3 SENSOR FREESTYLE LIBRE 3 SENSOR PLUS GUARDIAN 4 GLUCOSE SENSOR GUARDIAN 4 TRANSMITTER GUARDIAN CONNECT TRANSMITTER GUARDIAN LINK 3 TRANSMITTER GUARDIAN SENSOR 3 EVERSENSE E3 SENSOR-HLDR EVERSENSE SENSOR-HOLDER FREESTYLE LIBRE 14 DAY READER FREESTYLE LIBRE 14 DAY SENSOR FREESTYLE LIBRE 2 READER FREESTYLE LIBRE 2 SENSOR |
DEXCOM G4 (PED) RECEIVER KIT DEXCOM G4 RECEIVER KIT DEXCOM G4 RECEIVER-SHARE (PED) DEXCOM G4 RECEIVER-SHARE KIT DEXCOM G4 TRANSMITTER KIT DEXCOM G5 RECEIVER KIT DEXCOM G5 TRANSMITTER KIT DEXCOM G5-G4 SENSOR KIT DEXCOM G6 RECEIVER DEXCOM G6 SENSOR DEXCOM G6 TRANSMITTER DEXCOM G7 RECEIVER DEXCOM G7 SENSOR DEXCOM RECEIVER KIT *Dexcom products will require prior approval effective 1/1/2025. |
| AZOPT 1% EYE DROPS BRINZOLAMIDE 1% EYE DROPS |
DORZOLAMIDE HCL 2% EYE DROPS |
| BEPREVE 1.5% EYE DROPS BEPOTASTINE 1.5% EYE DROP |
OLOPATADINE HCL 0.1% EYE DROPS OLOPATADINE HCL 0.2% EYE DROP AZELASTINE HCL 0.05% DROPS |
| DIHYDROERGOTAMINE 1 MG/ML AMP | SUMATRIPTAN 4 MG/0.5 ML CART SUMATRIPTAN 4 MG/0.5 ML INJECT SUMATRIPTAN 6 MG/0.5 ML CART SUMATRIPTAN 6 MG/0.5 ML SYRNG SUMATRIPTAN 6 MG/0.5 ML VIAL SUMATRIPTAN 6 MG/0.5ML AUTOINJ |
| DIHYDROERGOTAMINE 4 MG/ML SPRY TRUDHESA NASAL SPRAY |
SUMATRIPTAN 20 MG NASAL SPRAY SUMATRIPTAN 5 MG NASAL SPRAY ZOLMITRIPTAN 2.5 MG NASAL SPRY ZOLMITRIPTAN 5 MG NASAL SPRAY |