Changes for 2022
Anthem prescriptions with Express Scripts will be replaced by Cigna in 2022.
Under any Anthem plan option, you pay a percentage of the cost (or co-insurance) for preferred and non-preferred brand medication filled at a retail pharmacy. For generic prescriptions or those ordered through the Mail Order program, you just pay a flat copay. Preventive generics ordered through the Home Delivery Pharmacy are covered 100%. Prescription drug copays and co-insurance don't count toward either plan deductible or out-of-pocket maximum.
Prescription Drug Coverage
Your prescription coverage will differ depending on which of the Anthem Plans you are enrolled in:
Health Savings Account (HSA) Plan: Your prescriptions are subject to the deductible first and then your out-of-pocket maximum. There is one exception to this: If you fill a generic preventive prescription NortonLifelock will cover this at 100% at both retail and Mail Order.
Preferred Provider Organization (PPO) Plan: You pay a percentage (co-insurance) of the cost for preferred and non-preferred brand medication filled at a retail pharmacy. For generic prescriptions and those ordered through Mail Order, you pay a flat copay. Preventive generics are covered at a retail pharmacy and Mail Order at 100%. Your pharmacy charges will count toward your out-of-pocket maximum.
Regardless of which Anthem medical plan you are enrolled in, you’ll be required to fill your maintenance medications in a 90-day supply using Express Script’s Home Delivery program or at a CVS retail pharmacy.
* Number of days supplied may vary depending on the Specialty Drug List.
Preferred Drug List (Formulary)
The Preferred Drug List, or Formulary (pdf) is a list of medications selected by Anthem insurance plans in consultation with a team of health care providers. The Plans will generally cover the drugs listed in the Preferred Drug List as long as the drug is medically necessary and plan rules are followed.
Key things to know about the Formulary:
- The Formulary is subject to change and is typically updated and posted between October and December every year.
- Drugs that appear on a Preferred Drug List have been chosen on the basis of sound medical data, safety and cost. Both brand-name and generic medications are on Express Scripts’ Preferred Drug List and have been approved by the Food and Drug Administration (FDA) as safe and effective.
- If your current drug is not on Express Scripts’ Preferred Drug List, consider speaking to your prescribing physician about alternative drugs that are on the list.
- Certain prescription drugs are excluded. For example, Renova, Vaniqa, Rogaine and over-the-counter drugs are excluded entirely. Botox, myobloc, immunization agents, certain contraceptive devices and nutritional/dietary supplements are generally excluded but may be covered under the medical plan. If you have questions about whether a prescription drug is covered, contact Collective Health at 1-833-834-1157.
- Dispense-as-written (DAW) requirement: If your doctor writes a brand-name prescription when a generic equivalent is available, you will pay the regular copay plus the difference in cost between the brand-name and generic drug. To obtain an exception, your doctor must contact Express Scripts to explain why a generic equivalent isn’t acceptable.
Preventive Generic Prescriptions
Preventive generics are covered at a retail pharmacy and Mail Order at 100%. Your pharmacy charges will count toward your out-of-pocket maximum. Regardless of which Anthem medical plan you are enrolled in, you’ll be required to fill your maintenance medications in a 90-day supply using Express Script’s Home Delivery program or at a CVS retail pharmacy.
Certain drugs require pre-certification prior to being filled. Pre-certification is designed to help encourage appropriate use of certain drugs in accordance with current medical findings, FDA-approved manufacturer labeling information, and cost and manufacturer rebate arrangements. The pre-certification list consists of drugs identified as having a narrowly defined use, as being more likely to be taken inappropriately or for too long a time period, or as being more expensive than other drugs that have been shown to be clinically or therapeutically similar. The pre-certification list is subject to change.
Anthem plan participants will have certain specialty medication prescriptions managed by Accredo, the specialty pharmacy for Express Scripts, which will help you better manage any out-of-pocket costs. Check to see if a prescription is affected.
Step Therapy Prescription Management Program
All Anthem participants are subject to the Step Therapy Program. The purpose of the program is to encourage you and your physician to choose the most cost-effective, clinically appropriate medication as your first option before other more costly prescription medication options are considered.
The three steps of the Step Therapy program are:
- Step 1. Generic medication
- Step 2. Preferred brand medication
- Step 3. Non-preferred brand medication
The class of medications covered by the Step Therapy program include those used to treat several common medical conditions:
- Bladder problems
- Cholesterol lowering
- High Blood Pressure
- Mental Health
- Narcotic Pain Relievers
- Non-narcotic Pain Relievers
- Skin Conditions
- Sleep Disorders
The Diabetes Care Value and Pulmonary Care Value programs help to close gaps in care and reduce costs. Patients with diabetes or pulmonary conditions can fill 90-day prescriptions through the Express Scripts pharmacy or any preferred retail pharmacy, including CVS or Walgreens, that focuses on diabetes and pulmonary conditions.
Both programs provide access to:
- A team of specialist pharmacists
- A preferred quality pharmacy network
- Clinical programs, such as remote monitoring
Filling and Refilling Prescriptions
Your prescription drug plan offers services to make obtaining your prescriptions more convenient and inexpensive, depending on your circumstances.
Whether you are viewing the member website or using the Express Scripts mobile app, you can easily manage your prescriptions:
- Check order status
- Refill and renew prescriptions
- Check prices and coverage
- Find convenient pharmacies
- View your Rx claims and balances
- Pay your balance using a variety of payment options
- View our therapeutic resource center for information
To access the member website…
Log in to www.express-scripts.com. (Complete registration if this is your first visit. Be sure to have your member ID or SSN available).
If you have a NEW prescription…
Get Started by contacting your doctor to request a 90-day prescription that he or she can ePrescribe directly to Express Scripts.
Or print a form by selecting “Forms” or “Forms and Cards” from the menu under “Benefits,” print a mail order form and follow the mailing instructions.
Or call Express Scripts and they will contact your doctor for you.
Please allow 10 to 14 days for your first prescription to be shipped.
If you already have a prescription…
Check Order Status online or using the app to view details and track shipping.
Transfer retail prescriptions to home delivery. Just click Add to Cart for eligible prescriptions and check out. Express Scripts will contact your provider on your behalf and take care of the rest. Check Order Status to track your order.
Refill and Renew Prescriptions for yourself and your family while online or while using the app. Just click Add to Cart for eligible prescriptions and check out. Express Scripts will contact your provider on your behalf, if renewals are included, and take care of the rest.
If you would like to set up automatic refills, please follow the instructions in the Automatic Refills Member Guide (pdf).