Prescription Drug Coverage
What to Know
Prescription drug coverage is included with your Anthem medical plan, and you’ll pay less when you visit an in-network pharmacy.
How the Plan Works
Anthem PPO Members
Prescription drug benefits are administered by Anthem Blue Cross. You can get prescriptions filled at UC Health Centers with outpatient pharmacies, from an Anthem retail pharmacy or through 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 low-cost medication options, getting forms and enrolling in home delivery.
The Anthem 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.
Learn more about what you’ll pay when you need a prescription filled.
Anthem HMO Members
The HMO provides coverage only for prescriptions purchased at UC Health Centers and Anthem HMO pharmacies and mail order service. You can also use out-of-network pharmacies and file a claim for reimbursement.
Learn more about what you’ll pay when you need a prescription filled.
What’s Covered
Your prescription drug benefit includes coverage for medications on Anthem’s 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 or generic and specialty drugs, which could include those recently approved by the FDA.
What You Pay
Anthem PPO Members
(30-day supply)
(90-day supply)
From an Anthem PPO Network Provider
Tier 2 Preferred brand drugs: $20
Tier 3 Non-preferred brand or specialty drugs: $40
You can get 90-day fills at Anthem Retail90 pharmacies [PDF] for 3 times the copayment.
From an Out-of-Network Provider*
(up to $250 per prescription, retail only)
* 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.
Anthem HMO Members
(30-day supply)
(90-day supply)
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 a.m. to 8 p.m. for more information.
Anthem HMO members can call (833) 674-9257, Monday through Friday, 8 a.m. to 8 p.m.
Filling Prescriptions
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 [PDF] (Retail90 pharmacies are identified with asterisks).
UC Health Center Pharmacy
Prescription drug fills and refills are available at all UC Health Centers with outpatient pharmacies.
Mail Service
Get up to a 90-day supply of a 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.
Log in to anthem.com/ca (select Pharmacy) to enroll your medications in home delivery.
Specialty Medication Prescriptions
For prescription drugs used to treat complex conditions, Anthem offers members access to a specialty pharmacy.
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 have a specialty drug that will be administered by your doctor, call Anthem Monday through Friday, 8 a.m. to 8 p.m. for instructions.
- Anthem PPO members call, toll-free, (833) 674-9256.
- Anthem HMO members call (833) 674-9257, Monday through Friday, 8 a.m. to 8 p.m.
You can also fill specialty medications through a UC pharmacy.
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 you or 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 versus 10mg). 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.
Provider Contact Information
Graduate Medical Education Office
Anthem Blue Cross
Group Number: 281636
PPO members: (833) 674-9256, Monday through Friday, 8 a.m. to 8 p.m. PT
HMO members: (833) 674-9257, Monday through Friday, 8 a.m. to 8 p.m. PT
First Impressions (for first-time PPO and HMO plan members): (888) 831-2238
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