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Anthem Blue Cross : State-Sponsored Business Pharmacy Information for Providers

State-Sponsored Business Pharmacy Information for Providers

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Introduction 
Anthem Blue Cross is contracted with the California Department of Health Care Services (DHCS), the Managed Risk Medical Insurance Board (MRMIB) and L.A. Care Health Plan to provide Medi-Cal Managed Care and Healthy Families Services in California. At Anthem Blue Cross, we are committed to bringing the power of one of California's most respected companies to work for everyone in the Medi-Cal and Healthy Families program.  
Anthem uses a Preferred Drug List (PDL) which is a list of preferred drugs for physicians to prescribe. The goal of our pharmacy benefit is to ensure that members receive therapeutically appropriate drug therapy. Our ability to review both medical and pharmacy claims allows for integrated clinical programs that help facilitate comprehensive disease state management programs. Select drugs may require prior authorization.  
 
Pharmacy Benefits Menu  
 
Prescription Drug Benefits  
Anthem Blue Cross covers most of the drugs prescribed. In general, brand-name prescription drugs are covered only if there is no generic drug available. Anthem Blue Cross covers brand-name drugs in cases where the prescriber writes on the prescription that a brand-name drug is needed.  
Over-the-counter (OTC) drugs are covered for Medi-Cal and LA Care members with a written prescription. Most OTC drugs are not covered for Healthy Families members; Healthy Families members can obtain insulin and diabetic supplies with a prescription.  
 
Pharmacy and Therapeutics Process  
Anthem Blue Cross uses a chosen list of drugs called a “preferred drug list.” A group of doctors and pharmacists updates this drug list every three months. Updating this list helps to make sure that the drugs on it are safe and useful.  
 
Where to Get Prescriptions Filled  
Prescriptions can be filled at more than 5,000 retail pharmacies in California, and a listing of these pharmacies (pharmacy network) can be found in our Provider Directory. To verify pharmacy network participation or Anthem drug coverage, please call 1-800-700-2533. The TTY number for members with hearing or speech loss is 1-888-757-6034
Retail pharmacies can dispense no more than a 30-day supply, but most prescriptions can be written with refills.  
 
How to Use the Anthem Blue Cross’ Preferred Drug List/Formulary  
Anthem’s Preferred Drug List/Formulary lists the brand name or generic name of a given drug. If a medication does not appear on this Preferred Drug List/Formulary, the medication will require prior authorization to be covered under the pharmacy benefit. A prior authorization form will need to be completed by the prescriber and submitted to Anthem before the prescription may be filled. To obtain the prior authorization form, you can contact our pharmacy benefit manager’s Prior Authorization Center at 1-800-338-6180 for more information.  
State-Sponsored Business Approved Drug List/Formulary

Search by drug name or disease category to learn about prescription medications available in your plan.

 
Prior Authorization  
Prior Authorization is designed to encourage appropriate use of medications. Select medications on the Preferred Drug List may require prior authorization. Medication utilization must meet FDA-approved indications as well as Anthem medical necessity guidelines. If a medication requires prior authorization, a prior authorization form needs to be completed by the prescriber for submission to Anthem. To obtain a prior authorization form, you can contact our pharmacy benefit manager’s Prior Authorization Center at 1-800-338-6180 for more information. 
Synagis Prior Authorization Form
Medical Injectables Prior Authorization Form
 
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 prescribing any multi-source brand, prescribers are encouraged to consider using its preferred generic alternative. Brands with a generic alternative will require a written prior authorization and an internal review by Anthem to determine medical necessity for benefit coverage. 
 
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 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 Anthem to determine medical necessity.  
 
Benefit Exclusions  
The following medications are benefit exclusions that are not covered under the pharmacy benefit:  
Infertility medications
Cosmetic and hair medications
Dietary supplements, except for treatment of phenylketonuria (PKU)
Erectile dysfunction medications
Drugs not approved by FDA
 
Office-Based Injectables  
Drugs requiring the assistance of a medical professional (office-based injectables) are not covered under the pharmacy benefit. Medically necessary office-based injectables are covered under the major medical benefit. Please refer to the Member Handbook for more details on medical coverage. 
 
Cost to Member  
Currently there is no copayment for Medi-Cal and LA Care members. There is a $5 or $10 co-pay for Healthy Families members with a $250 maximum limit per family for both medical and pharmacy benefits for prescriptions.  
 
Important Toll-free Contact Numbers  
Express Scripts Prior Authorization: 1-800-338-6180  
Prescription Drug Plan: 1-800-700-2533 
Customer Service TTY line: 1-800-247-9843  

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2011 Anthem Blue Cross.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.