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5 Things to Know About the New Rx Administrator

1. What’s Covered and What You Pay 2. Filling Prescriptions 3. Restrictions and Rules 4. Transitioning Current Prescriptions to Anthem 5. You Can Save on Prescriptions All Year

1. What’s Covered and What You Pay

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).

What You Pay 

 
HSP

In-network

You pay the full cost of prescriptions until you reach the plan deductible. After that, you pay 20% for most covered drugs.

The mail service offers convenient refills delivered by mail to your home.

Out-of-network

You pay the full cost of prescriptions until you reach the plan deductible. After that, you pay 40% for most covered drugs.

UC Care

In-network (30-day supply)

(Preferred Generic) Tier 1: You pay $5

(Preferred Brand) Tier 2: You pay $25

(Non-Preferred) Tier 3: You pay $40

(Speciality) Tier 4: You pay 30% of the cost (up to $150 maximum)

Mail service (90-day supply)

(Preferred Generic) Tier 1: You pay $10

(Preferred Brand) Tier 2: You pay $50

(Non-Preferred) Tier 3: You pay $80

(Speciality) Tier 4: You pay 30% of the cost (up to $150 maximum)

Out-of-network

You pay 50% of the cost.

CORE

In- and out-of-network

You pay the full cost of prescriptions until you reach the plan deductible. After that, you pay 20% for most covered drugs.

2. Filling Prescriptions

At a Retail or UC Medical Center 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.)

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, and your prescription is delivered to you by mail.

Specialty Medications

For prescription drugs used to treat complex conditions, Anthem offers members access to a specialty pharmacy called Accredo featuring 24-hour support from pharmacists and nurses, home delivery, and refill reminders so you never miss a dose.

3. Restrictions and Rules

Prior authorizations or approvals for exceptions to prescription benefit rules and regulations (e.g., quantity limits, step therapy, or using a brand name drug instead of generic) that are still active on December 31, 2017 will be honored by Anthem for as long as you are taking that specific medication.

The following restrictions and rules will apply to new medications prescribed on or after January 1, 2018.

For questions, call Anthem Health Guide at (844) 437-0486, Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific).

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.

4. Transitioning Current Prescriptions to Anthem

Most open prescriptions will transfer automatically*:

  • If you have an open prescription at a retail pharmacy, simply show your new ID card when you get your first prescription filled in January 2018.
  • Most open mail order prescriptions will be transferred to the Anthem mail service vendor, Express Scripts.

For questions about transitioning your current prescriptions to Anthem, call Anthem Health Guide at (844) 437-0486, Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific).

*By law, certain prescriptions cannot be automatically transferred. If your prescription cannot be transferred, Anthem will notify you. Or call Anthem Health Guide at (844) 437-0486 during Open Enrollment to confirm if your prescription can be transferred, or to get answers to your questions about the transition.

Your Prescription Drug To-Do List

  • Check the Anthem drug list and prescription drug costs. Anthem uses a different drug list than OptumRx. Talk to your doctor about alternatives to lower your cost.
  • Get help: If you’re taking a drug that’s not on the Anthem drug list or have other questions, call Anthem Health Guide at (844) 437-0486, Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific).

Before December 31

  • Get refills of any daily medication so that you have enough to last through early 2018.
  • If your refills will expire on or around January 1, ask your doctor to write a new prescription (with refills) that you can submit to Anthem in January. (Active prescriptions will be automatically transferred.*)
  • Register with optumrx.com for access to 2017 prescription information.
  • Submit any new mail order prescriptions to the Anthem mail service.

On or After January 1, 2018

  • Show your new ID card at the pharmacy on your first visit in 2018; otherwise your claims may be delayed or processed incorrectly.
  • Register on anthem.com/ca to access cost information and the prescription drug mail order pharmacy. After registering click on Benefits > Pharmacy. On your first visit, register on the Express Scripts website. After that, you’ll be able to access medical and pharmacy information just by logging in to anthem.com/ca.

5. You can save on prescriptions all year

Anthem offers alternatives that can help you save money on your prescriptions.

  • 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.