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Pharmacy

How the Plan Works What's Covered and What You Pay for Prescription Drugs Filling Prescriptions Money-Saving Options Rules and Restrictions

How the Plan Works

Pharmacy benefits are administered by Anthem Blue Cross. Log in to anthem.com/ca to access a variety of tools—from viewing the drug list and finding local in-network pharmacies, to accessing tools to find low-cost medication options, getting forms and information about home delivery. (On your first visit, register with both Anthem and Express Scripts—Anthem's pharmacy administrator.) If you use an out-of-network retail pharmacy, you will be responsible for 40% of the maximum allowed amount and all costs above the maximum allowed amount for each medication. You’ll pay up-front and then submit a claim form to be reimbursed for 60% of the maximum allowed amount for each medication.

Anthem provides resources for managing your prescription drug coverage. Visit anthem.com/ca to access a variety of tools to find local in-network pharmacies, choose the lowest-cost medication option, view the drug list, access forms and get information about home delivery.

What’s Covered and What You Pay for Prescription Drugs

What’s Covered

Your prescription drug benefit includes coverage for medications on the Anthem National Drug List. The drug list—also called a formulary—is composed of drugs approved for the U.S. Food and Drug Administration (FDA), including brand-name and generic drugs. Medications on the list are grouped into four tiers.

  • Tier 1: These are typically generic drugs that offer the lowest-out-of-pocket costs and greatest value compared to other medications that treat the same condition.
  • Tier 2: These may be preferred or brand-name drugs or more expensive generic medications.
  • Tier 3: These are typically non-preferred and some specialty drugs, which could include those recently approved by the FDA.
  • Tier 4: These are typically specialty drugs used to treat complex, chronic conditions. Tier 4 drugs typically have the highest out-of-pocket costs.

For questions about what's covered and your costs, call Anthem Health Guide at (844) 437-0486, Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific). Pharmacy representatives are available 24/7.

What You Pay

 

In-Network

UC Pharmacies & Participating Anthem Pharmacies

Out-of-Network

Non-Participating Pharmacies

UC Health Savings Account Contribution (use this to pay your initial expenses before you meet the deductible)

$500 for self coverage; $1,000 for family

$500 for self coverage; $1,000 for family

Calendar-Year Deductible

(Combined with Medical/Behavioral Health Out-of-Pocket Expenses)

Self: $1,350

Family: $2,700

Self: $2,550

Family: $5,100

Out-of-Pocket Maximum (Includes Pharmacy, Medical and Behavioral Health Out-of-Pocket Expenses)

The most you’ll pay for covered services in a calendar year.

Self: $1,300

Family: $2,600

Self: $2,500

Family: $5,000

Contraceptive Drugs and Devices

No charge Not covered

(Preferred Generic) Tier 1

After deductible:

Retail (30-day supply): 20%

Mail Service (up to a 90-day supply): 20%

After deductible:

Retail (30-day supply): 40%

Mail Service: Not covered

(Preferred Brand) Tier 2

After deductible:

Retail (30-day supply): 20%

Mail Service (up to a 90-day supply): 20%

Retail (30-day supply): 40%

Mail Service: Not covered

(Non-Preferred) Tier 3

After deductible:

Retail (30-day supply): 20%

Mail Service (up to a 90-day supply): 20%

Retail (30-day supply): 40%

Mail Service: Not covered

(Specialty) Tier 4 Accredo and select UC pharmacies (30-day supply): 20% (up to $200 maximum per prescription) Not covered
Smoking Cessation—Over-the-Counter and Prescription Drugs (prescription required) Retail (30-day supply): No charge Not covered
Diabetic Supplies (excluding syringes, needles, and non-formulary test strips) Retail (30-day supply): No charge (after deductible) Not covered

Filling Prescriptions

At a Retail Pharmacy

You can fill up to a 30-day supply through Anthem’s national network of over 69,000 retail pharmacies, or at a UCMC pharmacy. You can also get up to a 90-day supply at a Retail90 Pharmacy. (Retail90 pharmacies are identified with asterisks on the PDF.)

UCMC Pharmacies

Prescription drug fills and refills are available at many UC Medical Center pharmacies.

Mail-Service Prescriptions

Get up to a 90-day supply of medication without leaving home. Use the Anthem mail service for maintenance medications, such as those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure or high cholesterol. Home delivery makes it quick and convenient to fill. Start a new prescription and request refills online through Express Scripts (Anthem's mail service administrator), and your prescription is delivered to you by mail. Log on to anthem.com/ca to access the Express Scripts pharmacy.

Specialty Medication Prescriptions

For prescription drugs used to treat complex conditions, Anthem offers members access to a specialty pharmacy called Accredo.

Specialty prescription medications administered in your doctor's office (e.g., Botox) may be covered under your medical benefit (through CVS Specialty Pharmacy), not your prescription drug benefit. (CVS Specialty Pharmacy is different from the CVS retail pharmacy.) If you're having a specialty administered by your doctor, call Anthem Health Guide toll-free at (844) 437-0486 for information about actions you or your doctor need to take.

Money-Saving Options

Preferred Generics

Save money when you choose therapeutically equivalent generic equivalent medications over more expensive brand-name drugs. When your physician prescribes a brand name drug, ask if a generic equivalent is suitable for your condition. If a generic equivalent is available—and your doctor requests the brand-name instead—you’ll pay the cost of the generic drug plus the difference between the cost of the brand name drug and the generic equivalent.

Half Tablet

For medications that can be easily cut in half without compromising efficacy, you can save money by having your doctor write a prescription for double the strength (e.g., 20mg. vs. 10 mg). You’ll get the same dosage at half the out-of-pocket cost. Medications included in this program include Accupril, Crestor®, DiovanHCT®, Lexapro®, Losartan, Lovastatin, Paxil, Pravachol, Simvastatin, and Zoloft.

Specialty Split Fill

Many people stop taking newly prescribed specialty drugs (such as for oral oncology and iron toxicity) within the first 30 days of treatment because of side effects. This program gives you time to discover whether a certain class of drugs will work for you, without wasting money on unused medications or risking complications caused by discontinued use. Here’s how it works: When you receive a 30-day prescription, you’ll receive one 15-day supply at a prorated cost. This gives you two weeks to see how well you tolerate the drug or talk to your doctor about switching to a different medication.

Restrictions and Rules

Prior Authorization

Some drugs, and certain amounts of some drugs, require an approval by Anthem before they can be filled. Generally, your doctor must show that a particular drug is medically necessary.

Quantity Limits

Taking too much medication or using it too often isn’t safe, and may even increase your costs. If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, Anthem’s pharmacy system will reject your claim. 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.

Step Therapy

If your doctor prescribes a more expensive drug when a lower-cost alternative is available, you may be required to first try the less expensive drug that’s been proven to be effective before you can “step” up to the more expensive medication. Drugs that require step therapy include those used to treat ADHD, diabetes, high cholesterol, and multiple sclerosis.