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Member Eligibility & Benefits

Pharmacy Benefits

Medi-Cal Managed Care

Introduction

Anthem Blue Cross (Anthem) is contracted with the California Department of Health Care Services (DHCS) and L.A. Care Health Plan to provide Medi-Cal Managed Care (Medi-Cal) in California. At Anthem, we are committed to bringing the power of one of California's most respected companies to work for everyone in the Medi-Cal program.

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.

Prescription drug benefits

Anthem covers most of the drugs prescribed. In general, brand-name prescription drugs are covered only if there is no generic drug available. Anthem 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.

Pharmacy and therapeutics process

Anthem uses a chosen list of drugs called a “preferred drug list,” which is a list of preferred drugs for physicians to prescribe. 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 Directories. 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 formulary

Anthem’s formulary lists the brand name or generic name of a given drug. If a medication does not appear on this 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 the Prior Authorization Center at 1-800-338-6180 for more information.

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

Note: For Synagis or other medical injectable drug prior authorizations, please call 1-866-363-4126.

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. For Synagis or other medical injectable drug prior authorization forms, please call 1-866-363-4126.

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 Provider Manual for more details on medical coverage.

Cost to Member

Currently there is no copayment for Medi-Cal and LA Care members.

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