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Prescription Program
Drug List / FormularyAnthem Blue Cross and Blue Shield’s prescription drug benefits include medications available on the Anthem drug list/formulary. Our prescription drug benefits can offer potential savings Drug list effective as of
when your physician prescribes medications on the drug list/formulary. April 1, 2010
QUESTIONS & ANSWERS
Q. What is a drug list/formulary?
A. The Anthem Drug List/Formulary is a list of FDA-approved brand-name and generic medications
that have been reviewed and recommended for their quality and ef ectiveness by the National Pharmacy and Therapeutics (P&T) Commit ee. The P&T Commit ee is an independent group of practicing doctors and pharmacists responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and choose the top medications for our drug list—based on their safety, effectiveness and value.
Drugs on the Anthem Drug List/Formulary are grouped by ‘tiers.’ A number of factors are considered when classifying drugs into tiers, including, but 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.
Because the medications on the drug list/formulary are subject to periodic review, please ask your physician about the most current drug list additions and deletions or visit anthem.com.
Brand-name: A brand-name drug is usually available from only one manufacturer and may
Generic: A generic drug is required by the FDA to have the same active ingredients as its
brand-name counterpart, but is normally only available after the patent protection expires on a brand-name drug. Although it may look different, a generic drug works the same as its brandname counterpart. You can save money by using generic medications.
Q. What if my physician or I choose a brand-name drug when a generic equivalent is available?
A. In most cases, you would be responsible for the appropriate tier copay. This copay may include
an additional charge that represents the cost difference between the brand-name medication and Q. What are ‘clinically equivalent’ medications? How does this affect my drug coverage?
A. The P&T Commit ee reviews the most cur ent research available to determine if multiple drugs
used to treat a disease/condition produce the same clinical ef ect. When this is the case, the commit ee may recommend that we cover only the lower cost drug(s) as part of our ef ort to help reduce the overal cost of care. This means your specific prescription plan may not cover some drugs (indicated by a ^ symbol next to the drug name) in classes with ‘clinical y equivalent’ alternatives.
Q. What if my medication is not on the drug list/formulary?
A. An open drug list al ows members and their physicians to choose from a wide variety of prescription
medications. Please talk with your doctor about prescribing a Tier 1 or Tier 2 medication. If a Tier 3 medication is selected, you wil be responsible for the applicable Tier 3 copayment.
You or your physician may submit a request to add a drug to the drug list/formulary either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug Please contact the member services number on your ID card if you have questions.
Most Commonly Prescribed Medications from the Anthem Drug List
Tier 3: Brand (Tier 1 generics are available)
Tier 2: Brand
Lamictal tablets & chewable (lamotrigine) Sular 20, 30 & 40mg (nisoldipine) DO, QL Xopenex Neb. Soln 1.25/0.5 (levalbuterol) ^ This product has clinically equivalent alternatives included on the formulary and, as a consequence, such product may not be covered under your pharmacy benefit. Please consult your online pharmacy account through your health plan web site, www.anthem.com, for details on coverage.
PA PRIOR AUTHORIZATION REQUIRED – Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.
QL QUANTITY LIMITS – Certain prescription drugs have specific quantity limits per prescription or per month.
ST STEP THERAPY REQUIRED – You may need to use one medication before benefits for the use of another medication can be authorized. Please note: Foradil and Serevent are safety edits that
DO DOSE OPTIMIZATION REQUIRED – Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.
Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Member Services at
the telephone number listed on your identification card.
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For Kentucky residents only: In selecting medications for the drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is
in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a medication not included on the drug list (Tier 3). Anthem has criteria that permits a member to obtain a Tier 3 medication in a closed drug list plan. If specific criteria is met, the member can receive a Tier 3 drug for a drug list copay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. There is a process to request a medication be added to the drug list for any medications that do not meet the criteria.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, 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 most of Missouri: 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. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. (serving Virginia excluding 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”) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Source: http://legacy.mariemontschools.org/personnel/Files/Anthem/RX%20quick%20reference042010.pdf