Common Questions About Our Formulary
Generic and Brand Name Drugs
What is a Formulary (or Preferred Drug List) and how does it affect me?
A Formulary (or Preferred Drug List) is a list of brand-name and generic medications that have been rigorously reviewed and selected by a committee of practicing doctors and clinical pharmacists for their quality, cost savings, and effectiveness. If your prescription coverage includes a Formulary, you can save money by encouraging your doctor to prescribe you medications from this preferred list. In addition, your health plan reviews and approves the recommendations of this committee. Medications are not evaluated based on cost* unless therapeutic equivalence has been established.
How can a Formulary benefit me?
You can be confident that you're receiving FDA-approved medications that have been reviewed and selected for their quality, cost savings, and effectiveness by practicing physicians and clinical pharmacists. If your prescription coverage includes a Formulary, you will pay less for drugs your doctor prescribes from this preferred list.
How are prescription medications selected for the Anthem Prescription Formulary?
First, the Clinical Review Department reviews the medication's profile or its significant features and the treatments for which it will be used. Pharmacists evaluate the benefits of the new medication and compare them to existing therapies.
Next, they evaluate research studies that assessed the effectiveness of the medication and may perform a cost benefit analysis of the medication.
Finally, the Anthem Prescription and Therapeutics Committee discusses the findings and vote on whether to add or remove the medication on the formulary. When determining which drugs to approve, committee members consider medical literature and studies of each drug's effectiveness, safety, and cost, compared with other drugs in the same category.
Pharmacists also periodically review medications listed on the formulary by looking at additional research, pharmacy and medical claim utilization and current patterns of use. During this process, other medications new to the market are periodically entered into the formulary evaluation pipeline.
Will my doctor know about this Drug Formulary?
We've sent copies of our updated Drug Formulary to all prescribing providers, so your doctor knows where a medication falls on our Drug Formulary whenever he or she prescribes medications for you.
I'm interested in a new drug I've heard about. Is it covered yet?
New FDA-approved drugs are reviewed by our committee of practicing doctors and clinical pharmacists before being added to our Formulary. If you require a new drug that has not been reviewed yet, please call customer service at the number on the back of your ID card for assistance.
What if my medication is not on the Formulary?
Almost all Anthem products have an "open" formulary which allows members to receive prescription benefits for medications not listed on our Formulary, though the copay is generally higher. In special situations where a member may require the use of a non-formulary drug for clinical reasons, certain criteria can be met that would allow that member to receive the non-formulary drug at the formulary copay. This "benefit override" is part of Anthem's appeals process.
Can I request that a medication be added to the Formulary?
Yes. Your input is valuable because we want to maintain a formulary list that is acceptable to both our members and their providers. You can send your request for formulary changes to:
Formulary Addition Requests
Anthem Prescription Management, LLC.
Attn: Formulary Department
PO Box 746000
Cincinnati, OH 45274-6000
The Anthem Prescription Clinical Review Department responds to all requests for formulary additions.
What is the difference between generics and brands and how does it affect my benefits?
A brand-name drug is usually available from just one manufacturer and may have patent protection. Generics become available when a brand-name drug's patent expires and the drug meets the same U.S. Food and Drug Administration standards for safety, purity and potency. A generic drug has the same active ingredients as its brand-name counterpart, but is normally only available after the patent protection expires on a brand-name drug. Although it may look different, a generic drug works the same, must be absorded and utilized by your body and provides the same clinical benefits as its brand-name counterpart.
Check your Schedule of Benefits to know how the use of generic versus brand name drugs will affect your benefits. Due to lower copayments, you can save money by using generic medications whenever possible.
Are generic medications as safe and effective as brand-name drugs?
Yes. Generic medications are strictly regulated by the FDA. In order to pass FDA review and be A-rated ("therapeutically equivalent"), the generic drug must be identical to its counterpart brand-name medication in these ways:
| same active ingredients |
| same dosage form and strength |
| same medical effect|
Why are generic medications less expensive?
Normally, a generic drug can be introduced to the market only after the patent has expired on its brand-name counterpart. Generic drug manufacturers generally price their products below the cost of the brand-name versions.
Why are generic drugs important?
Depending on their plan design, members can help control the amount they pay for their prescriptions by requesting that their doctors prescribe generic medications. They do so without compromising the quality of their care.
How can I request a generic medication?
Your physician and pharmacist are the best sources of information about generic medications. Simply ask one of them if your prescription can be filled with an equivalent generic medication.
Can I have my prescription switched to a drug with a lower copayment?
Call your doctor and ask if it's appropriate for you to switch to another drug. The decision is up to you and your doctor.
Can I request a Brand-Name drug?
A patient may request that his or her doctor prescribe the brand-name drug even when a generic version is available. However, the patient will have to pay the difference in cost between the generic and brand-name drug, plus the copayment.
What is Therapeutic Interchange?
Therapeutic Interchange is a voluntary program that focuses on educating both physicians and members about high quality alternatives that may lower the member's prescription drug cost. Therapeutic Interchange converts non-Formulary and brand-name drug prescriptions to Formulary or generic equivalent medications. A non-Formulary-to-Formulary or brand-to-generic interchange may be initiated at the time medications are dispensed, or later, when claims data reveal a conversion opportunity.
Why are certain drugs selected for the Therapeutic Interchange program?
Medications selected for Therapeutic Interchange are evaluated by clinical pharmacists based on their efficacy, quality and cost-effectiveness. Each medication recommended for Therapeutic Interchange must also be approved by Anthem Prescription's Pharmacy and Therapeutic Committee, which includes practicing physicians and clinical pharmacists.
How does Therapeutic Interchange work?
When a Therapeutic Interchange opportunity is identified by the claims processing system, the prescribing physician is sent relevant clinical data about the proposed therapeutic interchange. Upon request of the physician, a pharmacist will telephone the member in advance to discuss the interchange.
If the physician approves the therapeutic interchange, the new prescription is reviewed and validated by a pharmacist before it is filled. The member is notified in a letter that explains the therapeutic interchange.
If the physician does not approve the suggested therapeutic interchange, the member's file is marked to prevent future intervention on that medication.
Therapeutic Interchange is always voluntary on the part of the member's physician and the member. They may refuse any Therapeutic Interchange proposed by Anthem Prescription.