CurrentHighmark Blueshield NenyPolicy N/A

Free Market Health Drug List

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A combined listing of drugs included in the Free Market Health program, separated by medical benefit (HCPCS/J-codes and Q-codes) and pharmacy benefit (drug names), indicating effective dates; applies to Highmark Blueshield Neny members and providers relying on the payer's drug list.

Policy Summary

PayerHighmark Blueshield Neny

PolicyFree Market Health Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionConsult the drug list to determine whether a product is assigned to the medical or pharmacy benefit and note the listed effective date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2benefit sections (Medical and Pharmacy)

40+medical-benefit HCPCS/J/Q codes listed (partial)

200+pharmacy-benefit drugs listed (partial)

11/15/2022–06/15/2025effective date range

PAH/CFindication-specific limits noted

Covered Drugs by Benefit and Effective Date

Coverage listing (enumeration only)

Drugs included in the program by benefit with effective dates; no additional coverage criteria or exclusions are provided in this portion of the document.

List includes separate sections for Medical Benefit and Pharmacy Benefit drugs, with effective dates shown; no utilization management criteria are specified in this enumeration.

Medical benefit (examples)

Actemra IV (J3262) — Effective Date = 08/01/2021
Acthar (J0800) — Effective Date = 04/18/2022
Ahzantive (Q5150) — Effective Date = (listed)
Aldurazyme (J1931) — Effective Date = (listed)
Arcalyst (J2793) — Effective Date = (listed)
Avsola (Q5121) — Effective Date = (listed)

Pharmacy benefit (examples)

ABIRATERONE ACETATE — Effective Date = 01/01/2022
ABRILADA (CF) — Effective Date = 04/01/2024
ACTEMRA (pharmacy entry) — Effective Date = 04/18/2022
ADEMPAS — Effective Date = 11/15/2022
ADALIMUMAB — Effective Date = 12/01/2023
Many additional pharmacy benefit drug names are enumerated in the list with their effective dates (see document).

Drug list entries

Drug inclusion on the pharmacy benefit list with stated effective dates; some entries include indication-specific notes.

Pharmacy benefit drug entries

RETEVMO — Effective Date = 12/01/2021
REVATIO — Effective Date = 11/15/2022
RINVOQ LQ — Effective Date = 01/01/2025
SILDENAFIL CITRATE — Effective Date = 11/15/2022
*PAH Indications Only
TIOPRONIN DR — Effective Date = 04/01/2024
TOBI — Effective Date = 11/15/2022
TOBRAMYCIN SULFATE — Effective Date = 11/15/2022
*CF Indications Only
TALTZ — Effective Date = 04/18/2022
TIBSOVO — Effective Date = 12/01/2021
VOTRIENT — Effective Date = 01/01/2022
VOSEVI — Effective Date = 04/18/2022
XPOVIO — Effective Date = 12/01/2021
XTANDI — Effective Date = 01/01/2022
Additional pharmacy benefit drug names and effective dates are listed throughout the document (see full list).

Medical Benefit Codes and Drug Name Lists

Medical benefit HCPCS/J/Q codes (sample)HCPCS

J3262	Actemra IV
J0800	Acthar
Q5150	Ahzantive
J1931	Aldurazyme
J2793	Arcalyst
Q5121	Avsola

Drug list (names only)NDC

List of pharmacy benefit drug names with effective dates (no billing or NDC codes provided in these chunks)

What Providers Should Know / Do

Note

Drug list overview

The Free Market Health Drug List enumerates all drugs assigned to the program, separated by Medical Benefit (HCPCS/J/Q codes) and Pharmacy Benefit (drug names), and includes the effective date for each listing. Document updated 01/01/2026.

Prior Authorization

SILDENAFIL CITRATE — PAH indications only

SILDENAFIL CITRATE is listed on the Pharmacy Benefit Drug List with an effective date of 11/15/2022 and is limited to pulmonary arterial hypertension (PAH) indications only.

Entry: “SILDENAFIL CITRATE *PAH Indications Only, Pharmacy Benefit Drug List .Effective Date = 11/15/2022”

Prior Authorization

TOBRAMYCIN SULFATE — CF indications only

TOBRAMYCIN SULFATE is listed on the Pharmacy Benefit Drug List with an effective date of 11/15/2022 and is limited to cystic fibrosis (CF) indications only.

Entry: “TOBRAMYCIN SULFATE *CF Indications Only, Pharmacy Benefit Drug List .Effective Date = 11/15/2022”

Benefit Section Definitions and Indication Limits

Benefit section definitions — Medical Benefit Drug List and Pharmacy Benefit Drug List descriptions

Medical Benefit Drug ListEntries are shown with HCPCS/J-codes or Q-codes and an effective date (examples: J3262 Actemra IV — Effective Date = 08/01/2021; Q5150 Ahzantive — Effective Date = 01/01/2026).

Pharmacy Benefit Drug ListEntries are shown by drug name and effective date (examples: ABIRATERONE ACETATE — Effective Date = 01/01/2022; ACTEMRA — Effective Date = 04/18/2022).

PurposeIdentifies which products are assigned to the medical benefit (billed with HCPCS/J/Q codes) versus the pharmacy benefit (filled via pharmacy) for the Free Market Health program.

Effective dates shownEach listed entry includes an effective date indicating when the product was added to the respective benefit list (document shows multiple dates, e.g. 08/01/2021, 01/01/2022, 01/01/2026).

PAH-specific limitation — 'PAH Indications Only' annotation

Annotation text"*PAH Indications Only" — used to indicate that coverage on the Pharmacy Benefit Drug List applies only for pulmonary arterial hypertension (PAH) indications.

Example drugSILDENAFIL CITRATE is listed with the annotation '*PAH Indications Only' and an Effective Date = 11/15/2022.

Scope of limitationThe annotation restricts that drug's inclusion on the pharmacy benefit to PAH-specific uses as shown on the drug list entry.

Cystic fibrosis-specific limitation — 'CF Indications Only' annotation

Annotation text"*CF Indications Only" — used to indicate that coverage on the Pharmacy Benefit Drug List applies only for cystic fibrosis (CF) indications.

Example drugTOBRAMYCIN SULFATE is listed with the annotation '*CF Indications Only' and an Effective Date = 11/15/2022.

Related CF entriesAdditional CF-designated products in the pharmacy list include formulations noted with (CF) such as ABRILADA(CF) and ADALIMUMAB-AACF(CF) with their respective effective dates.

Policy Summary

PayerHighmark Blueshield Neny

PolicyFree Market Health Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionConsult the drug list to determine whether a product is assigned to the medical or pharmacy benefit and note the listed effective date.

SourceLink

On This Page

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Free Market Health Drug List

Customize your policy alerts

Sign up for all Highmark Blueshield Neny policy alerts

Know when Highmark Blueshield Neny releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Covered Drugs by Benefit and Effective Date

Coverage listing (enumeration only)

Drugs included in the program by benefit with effective dates; no additional coverage criteria or exclusions are provided in this portion of the document.

List includes separate sections for Medical Benefit and Pharmacy Benefit drugs, with effective dates shown; no utilization management criteria are specified in this enumeration.

Medical benefit (examples)

Actemra IV (J3262) — Effective Date = 08/01/2021
Acthar (J0800) — Effective Date = 04/18/2022
Ahzantive (Q5150) — Effective Date = (listed)
Aldurazyme (J1931) — Effective Date = (listed)
Arcalyst (J2793) — Effective Date = (listed)
Avsola (Q5121) — Effective Date = (listed)

Pharmacy benefit (examples)

ABIRATERONE ACETATE — Effective Date = 01/01/2022
ABRILADA (CF) — Effective Date = 04/01/2024
ACTEMRA (pharmacy entry) — Effective Date = 04/18/2022
ADEMPAS — Effective Date = 11/15/2022
ADALIMUMAB — Effective Date = 12/01/2023
Many additional pharmacy benefit drug names are enumerated in the list with their effective dates (see document).

Drug list entries

Drug inclusion on the pharmacy benefit list with stated effective dates; some entries include indication-specific notes.

Pharmacy benefit drug entries

RETEVMO — Effective Date = 12/01/2021
REVATIO — Effective Date = 11/15/2022
RINVOQ LQ — Effective Date = 01/01/2025
SILDENAFIL CITRATE — Effective Date = 11/15/2022
*PAH Indications Only
TIOPRONIN DR — Effective Date = 04/01/2024
TOBI — Effective Date = 11/15/2022
TOBRAMYCIN SULFATE — Effective Date = 11/15/2022
*CF Indications Only
TALTZ — Effective Date = 04/18/2022
TIBSOVO — Effective Date = 12/01/2021
VOTRIENT — Effective Date = 01/01/2022
VOSEVI — Effective Date = 04/18/2022
XPOVIO — Effective Date = 12/01/2021
XTANDI — Effective Date = 01/01/2022
Additional pharmacy benefit drug names and effective dates are listed throughout the document (see full list).

What Providers Should Know / Do

Note

Drug list overview

Prior Authorization

SILDENAFIL CITRATE — PAH indications only

SILDENAFIL CITRATE is listed on the Pharmacy Benefit Drug List with an effective date of 11/15/2022 and is limited to pulmonary arterial hypertension (PAH) indications only.

Entry: “SILDENAFIL CITRATE *PAH Indications Only, Pharmacy Benefit Drug List .Effective Date = 11/15/2022”

Prior Authorization

TOBRAMYCIN SULFATE — CF indications only

TOBRAMYCIN SULFATE is listed on the Pharmacy Benefit Drug List with an effective date of 11/15/2022 and is limited to cystic fibrosis (CF) indications only.

Entry: “TOBRAMYCIN SULFATE *CF Indications Only, Pharmacy Benefit Drug List .Effective Date = 11/15/2022”

Benefit Section Definitions and Indication Limits

Benefit section definitions — Medical Benefit Drug List and Pharmacy Benefit Drug List descriptions

Pharmacy Benefit Drug ListEntries are shown by drug name and effective date (examples: ABIRATERONE ACETATE — Effective Date = 01/01/2022; ACTEMRA — Effective Date = 04/18/2022).

PurposeIdentifies which products are assigned to the medical benefit (billed with HCPCS/J/Q codes) versus the pharmacy benefit (filled via pharmacy) for the Free Market Health program.

PAH-specific limitation — 'PAH Indications Only' annotation

Annotation text"*PAH Indications Only" — used to indicate that coverage on the Pharmacy Benefit Drug List applies only for pulmonary arterial hypertension (PAH) indications.

Example drugSILDENAFIL CITRATE is listed with the annotation '*PAH Indications Only' and an Effective Date = 11/15/2022.

Scope of limitationThe annotation restricts that drug's inclusion on the pharmacy benefit to PAH-specific uses as shown on the drug list entry.

Cystic fibrosis-specific limitation — 'CF Indications Only' annotation

Annotation text"*CF Indications Only" — used to indicate that coverage on the Pharmacy Benefit Drug List applies only for cystic fibrosis (CF) indications.

Example drugTOBRAMYCIN SULFATE is listed with the annotation '*CF Indications Only' and an Effective Date = 11/15/2022.

Related CF entriesAdditional CF-designated products in the pharmacy list include formulations noted with (CF) such as ABRILADA(CF) and ADALIMUMAB-AACF(CF) with their respective effective dates.