Formulary Exceptions



You can ask Highmark Wholecare Medicare Assured  to make an exception to our coverage rules**.

Contact us from 8:00am-8:00pm, Eastern Time:
7 Days a week from October 1st through March 31st
*From April 1st through September 30th our business hours are 8:00am-8:00pm, Monday through Friday.

Pennsylvania Residents:   Call 1-800-685-5209

TTY users should call 711

You can mail or fax your request to**:

Address

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

Fax Number

 1-888-447-4369

**If the request is submitted by the member, the prescribing physician or other prescriber must submit a statement to support the request for coverage determination. The physician or other prescriber should also indicate whether or not the member’s health could be seriously harmed by waiting three days for a decision on this request.

There are several types of exceptions that you can ask us to make:

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to 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.

If your drug is in a cost-sharing tier and you think the cost is too high, you can ask for us to cover your drug at a lower cost-sharing tier. We do not lower the cost-sharing amount for drugs in the Specialty tier.

Generally, Highmark Wholecare will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you must submit a statement from your physician supporting your request.  

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.  Your physician can contact Highmark Wholecare via phone or complete the Medicare Request for Drug Coverage Form.

What if my request for exception is denied?

You have the right to request Reconsideration (redetermination) of this denial.  To file your request by phone:

Pennsylvania Residents:   Call 1-800-685-5209

TTY users should call 711

Or you can use the Request for Redetermination Form to file your request.  Your doctor may also make this request for you. 

If you wish to have someone else make this request for you, you must include a completed Highmark Wholecare Medicare Assured Appointment of Representative Form (pdf) to give this person permission. 

If you wish to send us your request in writing, you may fax it to us at 412-255-4503.  You may hand deliver or mail your request to this address:

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

You may also wish to refer to the Highmark Wholecare Medicare Assured Evidence of Coverage for further details about the reconsideration process and further appeal options. 



This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 27 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

Health benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare”). Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal.



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