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

State-Sponsored Business Pharmacy Information for Providers

PW_E173655
Introduction  
The Access for Infants and Mothers (AIM) Program is low-cost health coverage for pregnant women. Their newborns may be automatically eligible for enrollment in the Healthy Families Program. AIM is designed for families in the middle-income bracket who do not have health insurance and whose income is too high to qualify for Medi-Cal. You may also qualify for AIM coverage if you have health insurance but you have a separate maternity services deductible or co-payment of more than $500. Anthem Blue Cross contracts with the State of California to provide services to eligible members through our PPO or HMO, based on where the member lives. 
 
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 and a list of drugs that require prior authorization, please go to the website, http://www.anthem.com/pharmacyinformation. Alternatively, you can contact Express Scripts’ Customer Care at 1-866-629-1611 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.  
Prescription Drug 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
 
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 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 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  
No copayment per prescription for up to a 30-day supply for brand-name or generic drugs, including smoking cessation drugs, from an in-network retail pharmacy
No copayment per prescription for up to a 60 day supply for brand-name and generic drugs including smoking cessation drugs, through our prescription drug plan’s home delivery program
No copayment for FDA-approved contraceptive drugs or devices
 
Important Toll-free Contact Numbers  
Prescription Drug Plan: 1-800-700-2533  
Prescription Drug Plan TTY line: 1-800-905-9821  
Anthem Blue Cross Customer Service: 1-877-687-0549  
Customer Service TTY line: 1-888-757-6034  

® 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.