When reviewing the following information regarding pharmacy benefits, please note that this information is being provided for general information purposes only. This information including the programs referenced are not the practice of medicine, medical advice, or the substitute for the independent medical judgment of a physician. Only a physician can determine what medications are appropriate for a patient. The programs referenced are for the purposes of benefit determination only. Certain programs referenced by this information are not applicable to all Anthem Blue Cross plans. Please refer to the applicable member's Evidence of Coverage (EOC) for information on Plan benefits, conditions, limitations and exclusions. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
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How do I use my prescription benefits?
We offer access to a broad retail pharmacy network that includes thousands of pharmacies throughout the United States. That means you have convenient access to your prescriptions wherever you are — at home, work or even on vacation. For a list of participating pharmacies, access the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select “Find a Pharmacy” in the “My Prescription Plan” section.
You’ll get the most from your benefits by using a participating pharmacy. Choosing a non-network pharmacy means you’ll pay the full cost of the prescription up front. Then you must submit a claim form to your health plan for reimbursement.
How do I access my retail pharmacy network?
Some pharmacy benefit plans do not provide coverage for medications not listed on the Formulary, while others may provide coverage if the prescribing physician deems the medication medically necessary. Please refer to your Evidence of Coverage booklet for further benefit details, limitations, and exclusions.
How do I order medications using home delivery?
If your coverage includes a pharmacy benefit and you take maintenance medications, you can typically get a 90-day supply of your medication for the same price as two 30-day prescriptions filled at a retail pharmacy. Check your policy terms for details. Home delivery is a service for members who take maintenance medications such as for hormone replacement, asthma, diabetes, high blood pressure, arthritis, and any other conditions that require you to take a drug on an ongoing basis. It offers the convenience of having prescriptions filled using home delivery. Simply pick up the phone or submit your order online, and your medications are delivered directly to your home, office or anywhere in the United States. To order refills of your medications online if you have home delivery, log in to the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select “Order Refills” in the “My Prescriptions” section.
What is a Drug List/Formulary?
Your health plan uses what is called a “Preferred Formulary” that we also refer to as the “drug list” or just the “formulary.” This drug list/formulary contains brand-name and generic medications approved by the Food & Drug Administration (FDA) that have been reviewed and recommended by our Pharmacy and Therapeutics (P&T) Committee. Our P&T Committee is an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and chooses the medications for our drug list — based on various factors, including their safety, effectiveness and value.
If your doctor prescribes a drug that is not listed on the drug list, you may be subject to extra out-of-pocket cost. Because the medications on the drug list/formulary are subject to periodic review, call the Customer Service number on the back of your ID card to determine which medications are included. To obtain a copy, you can also get this information online by logging in to your health plan’s website.
What is a tiered drug list/formulary?
A tiered drug list/formulary assigns medications to specific levels, such as Tier 1, 2 or 3, based on various factors. Generic medications have the most affordable copay; brand-name medications, both preferred and non-preferred, usually cost more. Each of these medications is placed on tiers based on certain factors. These include, but are not limited to, the absolute cost of the drug, the cost of the drug relative to other drugs in the same therapeutic class, the availability of over-the-counter alternatives, and other clinical and cost-effectiveness factors.
What if my medication is not on the drug list/formulary?
If a drug your doctor prescribes is not on our drug list/formulary, we offer an “open drug list/formulary” that allows you and your physician to choose a prescription medication that is not on the drug list, as long as it is approved by the FDA. But it’s important to note that choosing medications that are not on our drug list/formulary will increase your out-of-pocket costs. Please talk with your doctor about prescribing a medication that is on the drug list/formulary when appropriate. If a medication is selected that is not on your drug list/formulary, you will be responsible for the applicable non-formulary cost share amount.
You or your physician may submit a request to add a drug to the drug list either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list/formulary review process.
Inclusion of a medication on the drug list/formulary is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions.
What is the Preferred Drug Program?
To better manage the increasing cost of prescription drugs and facilitate access to safe, effective medications, we developed the Preferred Drug Program (PDP). The PDP promotes the use of select medications within a certain class of medications that are equally safe and effective in treating a specific illness or condition. If your physician prescribes a medication that is listed as a non-preferred alternative on this list, the medication will not be covered unless your physician deems that it is medically necessary for you to be on the non-preferred medication and indicates DAW or DNS on the prescription.
What is the difference between the Preferred Drug Program (PDP) and other managed care plans’ “closed formulary” programs?
While Closed Formulary programs typically contain a large number of drugs that may require extensive efforts to access these drugs, the PDP contains only a few non-preferred drugs. But most importantly, it remains flexible and sensitive to the needs of our members and providers. Non-preferred drugs are available through Anthem Blue Cross’ network of community pharmacies when deemed necessary by the prescribing physicians.
The PDP does not apply to all pharmacy benefits. Please refer to your Evidence of Coverage (EOC) for benefit details, limitations and exclusions.
Is the decision to include a particular drug in the PDP based exclusively on cost?
No. Safety and efficacy are always our first considerations, with cost as a deciding factor only when medical literature has shown equal safety and efficacy between drugs within a therapeutic class.
How much will I pay for my prescriptions?
In most cases when you use a participating pharmacy, you will be required to pay a fixed co-payment. (Depending on your policy, coinsurance may apply). In general, you will pay the least amount for generic medications and the highest amount for non-preferred/non-formulary medications. However, there may be exceptions based on our drug list tiers. Having your doctor prescribe generic drugs or drugs listed on your plan’s drug list/formulary can help reduce your total prescription out-of-pocket costs.
What is a prior authorization and step therapy?
Certain prescription drugs (or the prescribed quantity of a drug) may require “prior authorization” before you can fill the prescription. Some drugs require prior authorization because they may not be appropriate for every patient or may cause side effects. Your doctor should have a current list of drugs requiring prior authorization. However, your doctor may call our referral number for authorization and information regarding these requirements. Prior authorization helps promote appropriate utilization and enforcement guidelines for prescription drug benefit coverage.
In addition, “step therapy” involves medication that is prescribed only after you try a "first-line" drug. With step therapy, our P&T Committee recommends certain drugs as the first ones to try when starting or changing medication treatment. In instances in which one of these medications isn’t effective and/or appropriate for a particular member, the step therapy requirements allow the physician to then prescribe a different medication.
Your policy contains additional detail regarding prior authorization and step therapy, and lists the drugs that are subject to these requirements. For additional information, call the telephone number listed on the back of your ID card.
At the time you fill a prescription, your pharmacist is informed of the prior authorization or step therapy requirement through the pharmacy's computer system and is instructed to contact your health plan. The health plan will review the request and communicate the approval criteria to the requestor. If additional information is needed, the pharmacist may contact your prescribing physician.
Your doctor may also request an exception to the prior authorization/step therapy requirements, such as in instances in which you have an allergic or adverse reaction to the medication, or another documented reason that prevents you from following the prior authorization and/or step therapy requirements.
What do I need to do if one of my prescriptions requires a prior authorization or step therapy?
NYour doctor should have a current list of drugs requiring prior authorization or step therapy. The portion of your policy that explains your drug benefit also lists these drugs. When you fill your prescription at a retail pharmacy, your pharmacist will be notified that your medication requires prior authorization and will take the necessary steps to request it. If you use home delivery, your doctor must obtain prior authorization or follow the step therapy requirements before you can fill your prescription.
What is dose optimization?
When clinically appropriate, dose optimization typically involves changing from twice-daily dosing to a once-daily dosing schedule. For example, a 10mg dose taken twice per day would be changed to a 20mg dose taken only once per day.
For a few specific drugs, it is common practice for doctors to initially prescribe a lower strength of medication and then gradually move to higher strengths over a period of time. In these cases, the goal of dose optimization is to help ensure that as higher dosages are prescribed, the member takes a single dose at the higher strength.
If a member submits a prescription that exceeds the dosing limits set by the dose optimization program, the pharmacy’s computer will receive an electronic message that the prescription claim is being rejected due to Drug Utilization Review (DUR). The pharmacist may contact the doctor to determine if a different dose consistent with dose optimization guidelines is appropriate. If so, the drug is prescribed and filled at the new dosage. Or if there are medical reasons for the drug dosing schedule as originally prescribed, the doctor can request prior authorization review.
What are medication quantity limits?
Taking too much medication or using it too often isn’t safe and may even drive up your health care costs. Quantity limits regulate the amount of medication covered by your plan for a certain length of time. Most plans cover a 30-day retail pharmacy supply or up to a 90-day supply using home delivery. Quantity limits follow U.S. Food and Drug Administration (FDA) guidelines, as well as manufacturer recommendations.
If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, our pharmacy system will reject your claim. When this happens, the pharmacist receives an electronic “Invalid/Excessive Quantity” message. If your doctor believes your situation requires an exception, he or she may request prior authorization review. To avoid disrupting your treatment, you’ll be covered for the approved amount while review takes place.
When I submit a prescription, and my pharmacist receives an age or gender edit, what does that mean?
Certain drugs approved by the FDA or other prescribing guidelines include provisions that they are not appropriate for use based on a person’s age or sex.
If you submit a prescription that is impacted by these requirements, the pharmacy computer will receive an electronic message of “Indication Not FDA Approved” (gender edit) or “Non-Covered Prescription Item” (age edit). This lets the pharmacist know that your prescription drug plan will not cover the medication as prescribed. However, the prescribing physician may determine that important medical reasons exist for prescribing this medication as written. If this is the case, the physician may request prior authorization review.
What is the difference between generics and brands and how does it affect my benefits?
| Brand-name Drug: |
A brand-name drug is usually available from only one manufacturer and may have patent protection.
| Generic Drug: |
A generic drug is required by law to have the same active ingredients as its brand-name counterpart but is normally only available after the patent expires on a brand-name drug. You can typically save money by using generic medications.
Be sure to check your Schedule of Benefits to see how the use of generic versus brand-name drugs may affect your benefits and out of pocket costs. You may save money by using generic medications.
Are generic medications as safe and effective as brand-name drugs?
Yes. Generic medications are regulated by the FDA. In order to pass FDA review and be A-rated, the generic drug is required to be therapeutically equivalent to its counterpart brand-name medication in that it must have the same active ingredients, and the same dosage and strength.
Why are generic medications less expensive?
Normally, a generic drug can be introduced to the market only after the patent has expired on its brand-name counterpart and can be offered by more than one manufacturer. Generic drug manufacturers generally price their products below the cost of the brand-name versions.
Why are generic drugs important?
Depending on your benefit design, you can help control the amount you pay for your prescriptions by requesting that your doctor prescribe generic medications whenever appropriate.
How can I request a generic medication?
Your physician and pharmacist are the best sources of information about generic medications. Simply ask one of them if your prescription can be filled with an equivalent generic medication. You may be subject to higher cost sharing for brand drugs.
Can I request a brand-name drug?
Depending on the terms of your drug coverage, you may request that your doctor prescribe the brand-name drug even when a generic version is available. However, if a generic is available, you may have to pay the difference in cost between the generic and brand-name drug plus the generic co-payment.
Can I have my prescription switched to a drug with a lower co-payment?
If your current prescription medication is not a generic, call your doctor and ask if it's appropriate for you to switch to a lower cost generic drug. The decision is up to you and your doctor.
You can also select the “Save on My Prescriptions” link on Express Scripts’ website where you manage your current prescriptions. You’ll get information to discuss with your doctor and the tools to get started. To access Express Scripts’ website, visit the “My Pharmacy” section of your health plan website. No further login is required. On the Express Scripts site, select “Save on my Prescriptions” in the “My Prescriptions” section.
Can I get reimbursed for drugs I got from a pharmacy that is not in the network?
If your benefits include out-of-network coverage, you can get reimbursed for prescriptions filled at a non-network pharmacy, but it may cost you more. Be sure to take a claim form with you to the out-of-network pharmacy, complete it and mail the completed form to the address listed on the form. You can download a claim form by accessing the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select the Claim Reimbursement Form” in the “Printable Forms” section. You can also call the phone number on the back of your health plan ID card.
If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period?
If you are going to be out of town for an extended period and need medication, call the customer service number on the back of your member ID card to find a nearby participating national pharmacy. If you are planning to go out of the country, go to your local network pharmacy prior to your trip. Pay for the extra supply and send us a claim form. If you need to purchase drugs while out of the country, pay for the drug and send us a letter indicating your prescription, along with a receipt and a claim form.
If your coverage includes home delivery service, you can typically obtain up to a 90-day supply of your prescription maintenance drugs with your doctor’s prescription.
Why did I only receive part of my order through home delivery?
You may receive a partial order if a medication within your order cannot be filled right away while the other prescription is shipped separately to help avoid delay. The Prescription History page on Express Scripts’ website where you manage, and order and fill your prescriptions enables you to see when orders are partially shipped or if we need more information from you.
How do I file a paper claim form?
A call should be placed to customer service at the phone number listed on your ID card to request that a claim form be mailed
How do I get the most out of my Anthem Blue Cross pharmacy benefits?
| Present your Anthem Blue Cross prescription drug card when dropping off your prescriptions |
| Have your prescriptions filled at a participating pharmacy |
| Ask for generic or preferred medications to reduce your out-of-pocket cost |
| When possible, use home delivery for your prescriptions |