Please refer to the Preferred Drug List (PDL) when prescribing for our members. This guide does not contain a complete list of drugs; rather, it lists the preferred drugs within the most commonly prescribed therapeutic categories.
Though most medications on the PDL are covered without prior authorization, a few agents require you to contact the Pharmacy department for authorization.
You may reach the Pharmacy department at 1-844-396-2330 from 8 a.m. to 7 p.m. from Monday through Friday and 10 a.m. to 2 p.m. on Saturday.
The Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) PDL includes all medicines covered by Medicaid. You may need to get approval from us for certain drugs. This is known as prior authorization (PA). Your request should include why a specific drug is needed and how much is needed. You must get approval from us before a prescription can be filled. When there is a generic drug available, it will be covered. Requests for brand name drugs when generics are available will need a PA.
Providers can send a request for a prescription coverage determination via electronic prior authorization (ePA) rather than fax or phone.
Patients who are prescribed home infusion medications may need additional covered services as part of their care, even if the medications do not require precertification.
For durable medical equipment (DME), outpatient rehabilitation (physical therapy/occupational therapy/speech therapy), pain management, home care, home infusion or hyperbaric treatment, and wound care, please call the Pharmacy department at 1-844-396-2330 or fax to 1-866-920-8362.
Anthem’s drug coverage policies are based on medical necessity considerations subject to applicable benefits. Clinical pharmacy policy documents assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage, and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.
Our clinical policies can be found within our searchable formulary.
Pharmacy Hot Tips are brief messages to help answer questions and/or concerns you may have around a variety of pharmacy topics. Topics include preferred formulary products used to treat common diseases and conditions such as asthma and diabetes.
If you would like additional pharmacy information to assist our members, contact your Provider Relations representative at email@example.com to discuss having a Pharmacy Hot Tip prepared for you!