(Please note that any Preferred Drugs List (PDL) data displayed in this application is current as of 11/30/2006 and will be updated quarterly on this website.)
Ohio ABD Members rely on Anthem Blue Cross Blue Shield Plan Partnership, Inc. for coverage of safe and effective prescription medications. Anthem uses a Preferred Drug List (PDL) which a list of preferred drugs for physicians to prescribe. The goal of our pharmacy benefit is ensure that members receive therapeutically appropriate drug therapy.
Our pharmacy benefits are administered through WellPoint NextRx, our wholly-owned Pharmacy Benefits Management (PBM) company. Our ability to review both medical and pharmacy claims allows for integrated clinical programs that help facilitate comprehensive disease state management programs. Besides providing our members with safe and effective treatment options with our Preferred Drug List, Anthem also provides coverage for all drugs available through the Medicaid Fee-For-Service (FFS) Pharmacy Program. Select drugs may require prior authorization.
NOTE: ABD consumers new to managed care will be able to receive their prescription drugs with no new prior authorization requirements than traditional FFS Medicaid for the first three months they are enrolled in our plan. This means that if you needed a prior authorization under traditional Medicaid to get your prescription medication you will most likely still need a prior authorization to get the same medication. If you have not needed prior authorization under traditional Medicaid to get your prescription medication you will not need prior authorization from Anthem to get the same medication for the first three months you are enrolled. This will give you and your doctor time to consider other medications that do not require prior authorization and to learn the steps to getting prior authorization. Anthems ABD prior authorization (PA) list identifies all drugs that will require PA once you have been a managed care member for more than three months. If you are not sure when you will need to have your medication prior authorized or you have other questions about continuing to get medication, call Anthems Customer Care Center at (866) 896-6628. If you have a hearing loss, you can call the TTY line at 800-368-4424.
Prior Authorization (PA) Process
Anthem Blue Cross Blue Shield Partnership Plan, Inc. processes all prescription drug Prior Authorization requests in a timely manner, informing the prescribing physician and effected member of the outcome in writing. To initiate a Prior Authorization request:
| The prescribing physician must complete and fax the appropriate PA form to WellPoint NextRx at 888-382-5931 to be used by providers only |
| Upon receipt of the faxed request, WellPoint NextRx completes a medical review |
| A letter stating the approval of the PA request is faxed to the prescribing physician |
| When a determination cannot be reached with the information provided on the PA form: |
The physician is advised to fax additional medical documentation
After receipt of the additional information, the medical documentation will be reviewed and a determination can be made
| The prescribing physician and member will be notified of the final outcome |
| If the decision is a denial: |
The physician's letter includes denial reason(s) and the physician's name working for Anthem who issued the denial
The member's notification contains information regarding their rights to appeal and their rights to a state hearing
The state also receives a copy of the member's notification
| For an appeal of the denial, contact Anthem's Customer Care Center by calling (866) 896-6628. |
Prior Authorization applies to select medications.
Anthem's pharmacy benefit has a mandatory generic program. This Multi-Source Brand Prior Authorization program promotes the utilization of appropriate generic alternatives as first line therapies when medically appropriate. Prior to dispensing any multi-source brand, physicians are encouraged to consider using its preferred generic alternative. Brands with a generic alternative will require a written prior authorization for benefit coverage. Medications in this program require a written prior authorization submission for an internal review by WellPoint NextRx on behalf of Anthem to determine medical necessity.
The Dose Optimization Program, or dose consolidation, is an extension to the Quantity Supply Program which helps increase patient adherence with drug therapies. This program works with the member, the member's physician or health-care provider, and the pharmacist to replace multiple doses of lower strength medications where clinically appropriate with a single dose of a higher-strength medication (only with the prescribing physician's approval). Prior to dispensing of multiple doses of the lower strength medications, a written prior authorization needs to be submitted for an internal review by WellPoint NextRx on behalf of Anthem to determine medical necessity.
Quantity Supply Limits
Our pharmacy benefits allow up to a 30-day supply of medication. This program defines a standard 30-day supply of medication for a select list of medications. If a medical condition warrants a greater quantity supply than the defined 30-day supply of medication, Prior Authorization will ensure access to the prescribed quantity. Prior to dispensing, a written prior authorization needs to be submitted to WellPoint NextRx for an internal review on behalf of Anthem to determine medical necessity.
Benefit exclusions are those services that are not covered under the pharmacy benefit which include the following medications:
| Infertility medications |
| Erectile dysfunction medications |
| Drugs not approved by FDA |
Some drugs are best used after other effective, and usually less expensive, drugs have been tried first (first-line therapy). These agents are noted as Step Therapy products. When a prescription for a Step Therapy product is presented to the dispensing pharmacy, the online claims processor will search past claims for first-line therapy. The claim will be settled automatically if a first-line therapy is found. If a first-line therapy is not found, your pharmacist should call either the plan or your physician to discuss alternative prescription options.
Newly approved injectable medications that are FDA approved for self administration will be covered through the outpatient prescription drug benefit but will be subject to written prior authorization for up to one year from FDA approval.
Requests for self injectable medications will be approved when the following criteria are met:
| The injectable medication is FDA approved for self administration AND |
| The self injectable medication is prescribed for a FDA approved indication |
Prior to being dispensed, self injectable medications in this program require a written prior authorization submission for an internal review by WellPoint NextRx on behalf of Anthem to determine medical necessity.
Office Based Injectables
Drugs requiring the assistance of a medical professional (office-based injectables) are not covered under the pharmacy benefits. Medically necessary office-based injectables are be covered under the major medical benefits. Please refer to the Member Handbook for more details on medical coverage.
Through December 2007 Anthem will not require PA for any atypical anti-psychotic drug for our members in the Ohio ABD program. The following atypical anti-psychotic drugs will be available for our ABD members:
| Abilify |
| Clozaril |
| Geodon |
| Risperdal |
| Seroquel |
Any newly FDA-approved atypical anti-psychotic drugs will also be exempt from PA through December 2007.