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(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.  
 
Multi-Source Brands  
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.  
Dose Optimization 
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 
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
 
Step Therapy 
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. 
Self Injectables 
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.  
Antipsychotic Medications 
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
Zyprexa
Any newly FDA-approved atypical anti-psychotic drugs will also be exempt from PA through December 2007. 
Anthem Blue Cross Blue Shield Partnership Plan, Inc Preferred Drug List (PDF)
Preferred Drug List updates (PDF)
Epocrates
Prior Authorization (PA) List
Programs & Forms
 
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use