Highmark's Specialty Drug Management Arrangement Expanding to PA/DE/NY ACA Markets July 1!

Highmark's Specialty Drug Management Arrangement Powered by Free Market Health Expanding to PA/DE/NY ACA Markets July 1!

Highmark is excited to announce the launch of their specialty pharmacy arrangement powered by Free Market Health in the PA/DE/NY ACA Individual Markets effective July 1.  

Highmark has had this model in place with their large group fully insured and Medicaid books-of-business in Pennsylvania and Delaware since 2021.  During that time, they evaluated the performance of this value-based specialty pharmacy solution and made adjustments to maximize efficiency, savings and the clinical needs of our members. With this in mind, they are excited to introduce it to include the PA/DE/NY ACA Individual Markets.

What do I need to know?

Highmark's specialty pharmacy arrangement powered by Free Market Health is designed to bring members an enhanced clinical approach to the management of their specialty medication while containing the cost of the drug.

How does this work?

Highmark curated a network of high-quality specialty pharmacies with the help of Free Market Health. Pharmacies were hand selected based on their ability to manage specific conditions at competitive prices. These pharmacies are eligible to bid on the specialty prescription referrals for Highmark's membership.

When Highmark approves a prior authorization for a specialty medication it is routed to Free Market Health. Based on the member’s condition, the pharmacies have the opportunity to bid on filling the prescription and managing the medication for the lifetime of the prior authorization (typically one year). Since these specialty pharmacies were already vetted and determined to be high quality pharmacies for these conditions, whichever pharmacy offers the lowest price for the medication wins the bid and the patient is matched with them. From there, the pharmacy fills the medication and starts supporting that member in their care journey.

What can my client and/or members expect?

There should be no work on the client or member since pricing negotiations and matching a member to the best specialty pharmacy happens behind the scenes after Highmark approved a prior authorization for a specialty medication. What they can expect is cost savings and an improved patient experience as we transition to a value-based approach to specialty pharmacy management. With Free Market Health, each member using a specialty drug will be matched with the best pharmacy for their specific needs, meeting the member where they are in their care journey and considering the complexity of their condition.

Members can expect a superior level of service under this new arrangement including:

• 24/7 access to patient care advocates, specialty trained pharmacists and/or nurses with specialty condition experience.
• Ability to manage specialty medications on the specialty pharmacy’s website or mobile app.
• Refill reminders based on communication preferences – call, text, or email.
• Free delivery of medications on a day that works for the member – in some cases the specialty pharmacy will deliver to a local retail location.
• Most supplies, such as needles and syringes, are provided with specialty medication at no charge.
• Access to comprehensive, condition-specific patient care management programs. This clinical support is provided at no additional cost and member participation is completely voluntary.

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