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Pharmacy Coverage

How the Plan Works What’s Covered and What You Pay Filling Prescriptions Money-Saving Options Rules and Restrictions

How the Plan Works

PPO Members

Pharmacy benefits are administered by Anthem Blue Cross. You can get prescriptions filled at UC Medical Centers with outpatient pharmacies, from an Anthem retail pharmacy or the mail service. Log in to anthem.com/ca (select Pharmacy) 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. 

The PPO plan also covers a percentage of the cost of most prescription drugs purchased at out-of-network pharmacies. If you use an out-of-network pharmacy, you’ll pay the full cost upfront and file a claim for reimbursement. See What's Covered and What You Pay for details.

HMO Members

The HMO provides coverage only for prescriptions purchased at UCMC and Anthem HMO pharmacies. You can also use out-of-network pharmacies and file a claim for reimbursement. See What’s Covered and What You Pay for details. 

What’s Covered and What You Pay for Prescriptions

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 by the U.S. Food and Drug Administration (FDA), including brand-name and generic drugs. Medications on the list are grouped into three 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 brand/generic and specialty drugs, which could include those recently approved by the FDA.

What You Pay

PPO

  Tier 1
UC Medical Center
Tier 2
From an Anthem PPO Network Provider
Tier 3
From an Out-of-Network Provider1

Prescription Drugs: Retail

(30-day supply)

$10 for Tier 1 generic drugs

$20 for Tier 2 preferred brand drugs

$40 for Tier 3 non-preferred brand/ generic and specialty drugs

$10 for Tier 1 generic drugs

$20 for Tier 2 preferred brand drugs

$40 for Tier 3 non-preferred brand/ generic and specialty drugs

You can get 90-day fills at Anthem Retail90 pharmacies for 3 times the copay.

50% of the cost
(up to $250 per prescription, retail only)

Prescription Drugs: Mail Service

(90-day supply)

$10 for Tier 1 generic drugs

$30 for Tier 2 preferred brand drugs

$50 for Tier 3 non-preferred brand/ generic and specialty drugs

$10 for Tier 1 generic drugs

$30 for Tier 2 preferred brand drugs

$50 for Tier 3 non-preferred brand/ generic and specialty drugs

Not covered

1. In addition to any deductible and coinsurance, you are responsible for any billed charge that exceeds Anthem’s maximum allowed amount for services provided by an out-of-network provider. For outpatient non-emergency services or surgery at an out-of-network facility, the maximum plan payment amount is $350 per day. For outpatient surgery at an out-of-network ambulatory surgical center, the maximum plan payment amount is $350 per day. For inpatient non-emergency services at an out-of-network facility, the maximum plan payment amount is $600 per day.

HMO

  UC Medical Center Providers HMO Providers

Prescription Drugs: Retail

(30-day supply)

$10 for Tier 1 generic drugs

$20 for Tier 2 preferred brand drugs

$40 for Tier 3 non-preferred brand/ generic and specialty drugs

$10 for Tier 1 generic drugs

$20 for Tier 2 preferred brand drugs

$35 for Tier 3 non-preferred specialty drugs; drugs purchased at non-HMO pharmacies are covered at 50%, up to $250 per prescription

Prescription Drugs: Mail Service

(90-day supply)

$10 for Tier 1 generic drugs

$30 for Tier 2 preferred brand drugs

$50 for Tier 3 non-preferred brand/generic and specialty drugs

$20 for Tier 1 generic drugs

$40 for Tier 2 preferred brand drugs

$70 for Tier 3 non-preferred specialty drugs

Prior Authorization

Some medications require prior authorization by Anthem before the prescription can be filled.

  • Anthem PPO members can call, toll-free, (833) 674-9256, Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific) for more information.
  • HMO members can call (833) 674-9257 Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific).

Filling Prescriptions

At a Retail Pharmacy

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

UCMC Pharmacies

Prescription drug fills and refills are available at all UC Medical Centers with outpatient 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 and high cholesterol. Home delivery makes it quick and convenient to fill. Start a new prescription and request refills online through Anthem, and your prescription is delivered to you by mail. Log in to anthem.com/ca (select Pharmacy).

Specialty Medication Prescriptions

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

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 drug administered by your doctor, call Anthem Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific) for information about actions you or your doctor need to take.

  • PPO members call, toll-free, (833) 674-9256.
  • HMO members can call (833) 674-9257 Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific).

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 or not 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 to talk to your doctor about switching to a different medication.

Rules and Restrictions

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 a 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.