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

State-Sponsored Business Pharmacy Information for Providers

PW_E173657
Introduction 
Anthem Blue Cross has been a participating plan with California's Major Risk Medical Insurance Program since its inception. The Major Risk Medical Insurance Program offers subsidized coverage to Californians who are considered “high-risk” because of their medical conditions. These individuals are either medically uninsurable or are not able to obtain adequate coverage.  
In addition to participating as a managed care organization, Anthem Blue Cross also serves as the vendor responsible for administering this program for the State. Those duties include managing eligibility, enrolling members in their choice of health plan and collecting premiums for the program.  
Members rely on Anthem Blue Cross for coverage of safe and effective prescription medications. The goal of our pharmacy benefit is 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 has an annual $500 deductible that the member must satisfy before the plan will begin paying for covered services. Effective January 1, 2010, the member is responsible for charges for certain covered services subject to the deductible, and Anthem Blue Cross will not cover these services until the member meets the deductible in a calendar year.  
Maximum 30-day supply for prescriptions when filled at a retail pharmacy
Maximum 60-day supply for Home Delivery prescriptions filled through Express Scripts
$5 for generic drugs
$15 for brand-name drugs
$5 for generic drugs through home delivery prescription drug program
$15 for brand-name drugs through home delivery prescription drug program
 
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.  
 
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 Anthem Blue Cross’ Preferred Drug List/Formulary  
Anthem’s Drug List/Formulary lists the brand name or common name of a given drug. If a medication does not appear on this 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.  
Search the Preferred Drug List

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 Drug List/Formulary 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 1-866-338-6180 for more information.  
 
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 alternatives. 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 benefit allows a maximum 30-day supply for prescriptions when filled at a retail pharmacy and a maximum 60-day supply for prescriptions using home delivery.  
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: 
Non-medicinal substances or items
Infertility medications
Drugs furnished by a hospital, skilled nursing facility, rest home, sanatorium, convalescent hospital or similar facility
Drugs used for the primary purpose of treating infertility
Cosmetic and hair medications
Allergy desensitization products and allergy serum
All infusion therapy except self-administered injectables and aerosols
Brand-name medications that have generic equivalents
Drugs not approved by FDA
Dietary supplements, except for treatment of phenylketonuria (PKU)
Syringes and/or needles, except those dispensed for use with insulin
Drugs obtained outside of the U.S
Drugs and medications used to induce nonspontaneous abortions
Drugs or medications that may be obtained without a physician’s prescription (over-the counter medications), except insulin and niacin for cholesterol lowering
Prescription drugs that have nonprescription chemical and dosage equivalents
Pharmaceuticals to aid smoking cessation
Drugs used for weight loss except when medically necessary
Childhood immunizations
 
Cost to Member  
Once the annual $500 deductible is met $5 for generic drugs 
$15 for brand-name drugs
$5 for generic drugs through home delivery prescription drug program
$15 for brand-name drugs through home delivery prescription drug program
 
Important Toll-free Contact Numbers  
Prescription Drug Plan: 1 800-700-2533  
Express Scripts Prior Authorization: 1-800-338-6180  
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.