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If you are quarantined or asked by your doctor to get an additional supply of prescription drugs during the COVID-19 crisis, you can get a single refill before the normal refill date by calling Anthem Health Guide at (844) 437-0486. Your request will usually be approved within 24 hours. Pharmacy help is available 24/7.

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

Prescription drugs are managed through Anthem's pharmacy benefit manager, IngenioRx. Log in to Anthem (select Pharmacy) to access a variety of tools—from viewing the Anthem Essential Drug List and finding local in-network pharmacies, to accessing tools to price a medication, find low-cost medication options, getting forms and information about home delivery. If you use an out-of-network pharmacy, you’ll pay upfront and, after the deductible, will be reimbursed by Anthem at 50% of billed charges for covered drugs, with an out-of-pocket copayment maximum.

Anthem provides resources for managing your prescription drug coverage. Visit Anthem (select Pharmacy) 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 Essential 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



UC Pharmacies & Participating Anthem Pharmacies


Non-Participating Pharmacies

Calendar-Year Deductible

No deductible

No deductible

Out-of-Pocket Maximum (Includes Pharmacy, Medical and Behavioral Health Out-of-Pocket Expenses)1

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

Individual: $6,100

Family: $9,700

Individual: $9,600

Family: $20,200

Contraceptive Drugs and Devices

Retail (30-day supply): $0

Mail Service (up to a 90-day supply): $0

Retail (30-day supply): $0

Mail Service: Not covered

(Preferred Generic) Tier 1

Retail (30-day supply): $5

Mail Service (up to a 90-day supply): $10

Retail (30-day supply): 50%

Mail Service: Not covered

(Preferred Brand) Tier 2

Retail (30-day supply): $25

Mail Service (up to a 90-day supply): $50

Retail (30-day supply): 50%

Mail Service: Not covered

(Non-Preferred) Tier 3

Retail (30-day supply): $40

Mail Service (up to a 90-day supply): $80

Retail (30-day supply): 50%

Mail Service: Not covered

(Specialty) Tier 4 IngenioRx and select UC pharmacies (30-day supply): 30% (up to $150 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 Not covered

1. In-network (Anthem Preferred and UC Select) medical, behavioral health and prescription drug out-of-pocket copayment maximums count toward each other. In-network and out-of-network medical copayment maximums are separate—what you pay toward one doesn’t count toward the other. Annual out-of-pocket maximums include deductibles, copays, coinsurance and prescription drugs.

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 get up to a 90-day supply for the cost of two copayments at UC Friends pharmacies, including UCMC pharmacies, CVS (including inside Target stores), Walgreens, Safeway/Vons, and Costco.

A 90-day supply for the cost of three copayments is available at designated Retail90 Pharmacy. (Retail90 pharmacies are identified with asterisks on the PDF.) This applies to all medications that can be safely filled at that quantity, not just maintenance medications.

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 Anthem (select Pharmacy), and your prescription is delivered to you by mail. Log on to Anthem.

Specialty Medication Prescriptions

For prescription drugs used to treat complex conditions, Anthem offers members access to a specialty pharmacy. Log in to Anthem (select Pharmacy) for more information or call the Care Team at (833) 255‐0645.

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

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.