Common Questions About Our Drug List/formulary
Generic and Brand Name Drugs
What is a Drug List/Formulary and how does it affect me?
A Drug List/Formulary is a list of brand-name and generic medications that have been reviewed and recommended for their quality and effectiveness by our National Pharmacy and Therapeutics (P&T) Committee. Our P&T Committee is an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and choose the top medications for our drug list – based on their safety, effectiveness and value.
Because the medications on the drug list/formulary are subject to periodic review, please ask your physician about the most current drug list additions and deletions or visit anthem.com
Brand Name: A brand-name drug is usually available from only one manufacturer and may have patent protection.
Generic: A generic drug is required by the FDA to have 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 as its brand-name counterpart. You can save money by using generic medications.
How can a drug list/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 Drug List/Formulary, you will pay less for drugs your doctor prescribes from this preferred list.
How are prescription medications selected for the drug list/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 Pharmacy & Therapeutics Committee discusses the findings and vote on whether to add or remove the medication on the drug list/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 drug list/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 drug list/formulary evaluation pipeline.
Will my doctor know about this Drug List/Formulary?
We've sent copies of our updated drug list/formulary to all prescribing providers, so your doctor knows where a medication falls on our drug list/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 drug list/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 Drug List/Formulary?
An open drug list allows members and their physicians to choose from a wide variety of prescription medications. Please talk with your doctor about prescribing a medication that is on the drug list/formulary. If a medication is selected that is not on the drug list/formulary, you will be responsible for the applicable non-formulary co-payment.
You or your physician may submit a request to add a drug to the drug list/formulary either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list/formulary review process.
Inclusion of a medication on the drug list/formulary is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions.
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 absorbed 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, the generic drug must be therapeutically equivalent to its counterpart brand-name medication in these ways:
| same active ingredients |
| same dosage form and strength |
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. You or your physician may refuse any proposed therapeutic interchange.