- Insurer Name : Highmark Wholecare
- Address : 120 Fifth Ave, Pittsburgh, PA 15222
- Phone Number : 1-800-392-1147
- Website : https://www.highmarkwholecare.com/
- Medicare/Medicaid/TRICARE Support : Yes (Medicare, Medicaid)
- Specific Plans Offered : Provides Medicare Advantage plans and Medicaid plans. Highmark Wholecare Plans
Frequently Asked Questions:
What is pre-authorization?
Pre-authorization, also known as prior authorization, is a process where your healthcare provider must obtain approval from Highmark Wholecare before a specific medication or service is covered. This ensures the prescribed treatment is medically necessary and aligns with coverage policies.
Which medications require pre-authorization?
Certain medications on Highmark Wholecare's formulary require pre-authorization. These are indicated with a specific symbol in the "Notes & Restrictions" column of the formulary. You can search for your medication using the Medicaid Drug Search tool.
How can my doctor request pre-authorization for a medication?
Your doctor can submit a pre-authorization request through the CoverMyMeds platform, which streamlines the process. They can create a free account or log in to an existing one on the CoverMyMeds website. Alternatively, they can call Highmark Wholecare directly or complete the Medicare Request for Drug Coverage Form.
What if my medication isn't listed on the formulary?
If your medication isn't on the formulary, contact Member Services to confirm if it's covered. If it's not, your doctor can request a medication exception by documenting the medical necessity and previous unsuccessful treatments using the Medicaid Drug Exception Form.
Are there quantity limits on medications?
Yes, some medications have quantity limits based on FDA-recommended dosing. These limits are noted as "QL" in the formulary. Prescriptions exceeding these limits will require a medical exception request from your prescribing physician.
How can I contact Highmark Wholecare for questions about pre-authorization?
For any inquiries regarding pre-authorization, you can reach Member and Provider Services at 1-800-392-1147. TDD/TTY users can call 711. Additional contact information is available on our Contact Us section.
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