Guide to drug coverage under medical benefit

Prescription drugs are covered in two ways — through the Anthem pharmacy benefit or via medical benefit. The method of coverage depends on whether the drug is self-administered or administered by a healthcare professional at home (such as home infusion therapy) or given in a clinical setting, like a doctor’s office.

Member drug access

Drugs that are only administered to members by healthcare professionals are available under the medical benefit and can be obtained in several ways:

Buy and Bill: Physicians may purchase drugs directly through pharmaceutical wholesalers and distributors and submit a claim to Anthem. To review the list of services and drugs that are billable on the medical benefit for Anthem please refer to the State Fee Schedule.
Delivery: Physicians may call Anthem’s contracted Medical Specialty Pharmacy (MSP) or CVS Specialty^® and request delivery of a member-specific specialty medication that will be administered in their office
Referral: Physicians may refer their members to infusion suites and outpatient hospital services

For more information on self-administered prescription drugs and pharmacy benefit coverage, please visit the Anthem pharmacy page.

Drug Clinical Criteria

CarelonRx, Inc.

CarelonRx is an independent company providing pharmacy benefit management services on behalf of the plan. Clinical Criteria for drugs and biologics paid under the medical benefit for certain Medicaid markets can be found on the CarelonRx website.

State-specific custom medical criteria

The state-specific custom medical criteria for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit can be found on the Anthem's Clinical Criteria in New York page.

All other medical criteria

The Clinical Criteria for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit are available for certain Medicaid markets.

Access Clinical Criteria

Medical Specialty Pharmacy (MSP)

Anthem is pleased to announce a drug delivery option that enhances medication accessibility to both members and providers. Anthem is contracted with CVS Specialty^® as the MSP. CVS Specialty^® can deliver member-specific medication that is covered under the Anthem medical benefit to your office for administration to the member.

Delivery of medication

To set up delivery or check a prescription order status, please call 877-254-0015 and you will be transferred to a pharmacist for a verbal prescription order. Please plan to provide your member's Anthem ID (located on their ID card). Staff will obtain additional information necessary to support the delivery of the medication, including the need-by date. Please allow up to 10 days for processing and shipping. The staff will then make an outbound call to your member to obtain consent as needed to support the delivery of the medication to your office. Once all necessary information is obtained for shipping, the staff will make an outbound call to your office to confirm delivery.

You may also fax prescription orders to 866-336-8479, and a staff member will call your office to obtain additional information necessary to support the delivery of the medication, following the same steps and procedures as when you call.

Note: If it is an urgent medication request and the need-by date is less than seven days from the order date, please indicate this so the order can be expedited.

Prior authorization

Some medications require prior authorization before they can be paid. Please review the prior authorization lookup tool for a listing of covered drugs and any associated requirements. If prior authorization is required, you may request precertification by phone, fax, or electronically.

How to request prior authorization

To ensure timely review of the prior authorization request, please include the servicing medical specialty pharmacy and provider name during the prior authorization intake.

Request by phone

Phone: 800-450-8753
Monday – Friday, 8:00 am – 7:00 pm EST
Saturday 10:00 am – 2:00 pm EST

Request by fax

Medical injectables: 844-493-9206

Request for oncology medical injectables (Essential Plan members only)
Fax:
855-201-8530

Request electronically

CoverMyMeds

Electronic prior authorizations (ePA)

Electronic prior authorization requests can be submitted through CoverMyMeds, an independent company providing medication precertification services on behalf of Anthem.

Using CoverMyMeds for prior authorization requests

CoverMyMeds streamlines the medication precertification process, electronically connecting providers, pharmacists, and plan/Pharmacy Benefit Managers (PBMs) to improve time to therapy and decrease prescription abandonment with electronic prior authorization.

Prescribers can view real-time status of any medication precertification request submitted via ePA, phone, or fax by logging in to the CoverMyMeds website and entering the member’s information. Prescribers also have the option to contact CoverMyMeds directly by calling 866-452-5017 for questions, information, or website concerns, or via the live chat on their website.

Access CoverMyMeds

Home infusion therapy (HIT)

Home infusion therapy is the administration of prescription legend drugs through intravenous, intraspinal, epidural, or subcutaneous routes from the comfort of the member’s home. HIT is prescribed by a physician that both the physician and Anthem have determined to be medically necessary and must supervised by a qualified healthcare professional to the member in their residence.

Using CoverMyMeds for prior authorization requests

To find an in-network HIT provider or to get a specialty prescription filled, please use our Find Care tool.

Prior authorization lookup tool

To request or check the status of a prior authorization request or decision, access our interactive care reviewer (ICR) application via Availity Essentials. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.

Prior authorization lookup tool

Availity access

The Availity website offers healthcare professionals free access to real-time information and instant responses in a consistent format, regardless of the payer.