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Prior Authorization Forms

Anthem HealthKeepers Plus members rely on Anthem Blue Cross and Blue Shield’s affiliated HMO, HealthKeepers, Inc., for coverage of safe and effective prescription medications. HealthKeepers uses a Preferred Drug List (PDL), which is a list of preferred drugs for doctors to prescribe. The goal of our pharmacy benefit is to ensure that you 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  
HealthKeepers covers most of the drugs prescribed. In general, brand-name prescription drugs are covered only if there is no generic drug available. HealthKeepers 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 with a written prescription.  
Where Prescriptions Are Filled 
Prescriptions can be filled at more than 5,000 retail pharmacies in Virginia, and a listing of these pharmacies (pharmacy network) can be found in our Provider Directory. To verify pharmacy network participation or Anthem HealthKeepers Plus drug coverage, please call 1-800-901-0020.The TTY number for members with hearing or speech loss is 1-757-326-5185 (Tidewater Area) or 1-800-247-9843 (Outside Tidewater Area).  
Retail pharmacies can dispense no more than a 30-day supply, but most prescriptions can be written with refills.  
How to Use HealthKeepers’ Preferred Drug List  
HealthKeepers’ Preferred Drug List lists the brand name or generic name of a given drug. If a medication does not appear on this Preferred Drug List, 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 HealthKeepers 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/priorauth.html . Alternatively, you can contact Express Scripts’ Prior Authorization Center at 1-866-310-3666 for more information.  
Search Other Drug Lists
Search the Medicaid 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 Preferred Drug List may require prior authorization. Medication utilization must meet FDA-approved indications, as well as our medical necessity guidelines. If a medication requires prior authorization, a prior authorization form needs to be completed by the prescriber for submission to HealthKeepers. To obtain a prior authorization form, you can contact our pharmacy benefit manager’s Prior Authorization Center at 1-866-310-3666 for more information. 
Multi-Source Brands  
The Anthem HealthKeepers Plus 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 HealthKeepers 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 you, your 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 HealthKeepers 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 HealthKeepers 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
Cosmetic and hair medications
Dietary supplements, except for treatment of phenylketonuria (PKU)
Erectile dysfunction medications
Drugs not approved by FDA
Cost to Member  
There is 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 for our Medallion II members, but there may be a $2 copayment with a $180 maximum out-of-pocket or $5 copayment with a $350 maximum out-of-pocket for our FAMIS members. There is no copayment for FDA-approved contraceptive drugs or devices.  
Other Important Topics 
Pharmacy and Therapeutics Process
Important Toll-free Contact Numbers  
Anthem HealthKeepers Plus Member Services: 1-757-326-5090 (Tidewater Area) or 1-800-901-0020 (Outside Tidewater Area)
Anthem HealthKeepers Plus Member Services TTY line: 1-800-247-9843
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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