Please call 844-336-2676 or fax all retail pharmacy PA requests to 858-357-2612 beginning July 1, 2021. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 2019 List of Covered Drugs (Formulary), Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual, Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Provider Manual, MMP: Medical Injectables Prior Authorization Form, Drug List Addition/Clinical Criteria Change Request Form. The Blue Cross name and symbol are registered marks of the Blue Cross Association , Essential Drug List 3-Tier with 1a/1b (Searchable), Essential Drug List 4-Tier with 1a/1b (Searchable), Essential Drug List 5-Tier with 1a/1b (Searchable), National Drug List 3-Tier with 1a/1b (Searchable), National Drug List 4-Tier with 1a/1b (Searchable), National Drug List 5-Tier with 1a/1b (Searchable), National Direct Drug List 3-Tier (Searchable), National Direct Drug List 3-Tier with 1a/1b (Searchable, National Direct Drug List 4-Tier (Searchable), National Direct Drug List 4-Tier with 1a/1b (Searchable), National Direct Drug List 5-Tier (Searchable), National Direct Drug List 5-Tier with 1a/1b (Searchable), National Direct Drug List 3-Tier with 1a/1b (Searchable), Traditional Open Drug List 3-tier (Searchable), Traditional Open Drug List 3-tier with 1a/1b (Searchable), Traditional Open Drug List 4-tier (Searchable), Traditional Open Drug List 4-tier with 1a/1b (Searchable), Traditional Open Drug List 5-tier (Searchable), Traditional Open Drug List 5-tier with 1a/1b (Searchable), PreventiveRx Plus Drug List (Traditional Open), Legacy PreventiveRx Plus Drug List (Traditional Open), Legacy PreventiveRx Plus Drug List (Select), Specialty drugs not covered under the pharmacy benefit, Specialty drugs not covered under the medical benefit, Home Delivery and Rx Maintenance 90 Drug List, ACA Contraceptive for Religious Affiliate Groups. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Registered Marks of the Blue Cross and Blue Shield Association. Providers who do not contract with the plan are not required to see you except in an emergency. Make sure you have your medicines when you need them. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Be sure to show the pharmacy your Anthem member ID card. We are not compensated for Medicare plan enrollments. If you need your medicine right away, you may be able to get a 72-hour supply while you wait. 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. April 1 through September 30, 8:00 a.m. to 8:00 p.m.
Attention Members: You can now view plan benefit documents online. are preferred retail cost-sharing network pharmacies. If you have the Essential formulary/drug list, this PreventiveRx drug list may apply to you: If you have the National formulary/drug list, one of these PreventiveRx drug lists may apply to you: If you have the National Direct formulary/drug list, one of these PreventiveRx drug lists may apply to you: Anthem has aligned the National and Preferred Drug Lists. If you dont see your medicine listed on the drug lists, you may ask for an exception at submitmyexceptionreq@anthem.com or by calling Pharmacy Member Services at 833-207-3120.Youll be asked to supply a reason why it should be covered, such as an allergic reaction to a drug, etc. adding the new generic drug, we may decide to keep the brand name
This is known as prior authorization. Please refer to the Provider Manual for more details on medical coverage: We look forward to working with you to provide quality services to our members. The joint enterprise is a Medicare-approved Part D Sponsor. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. S2893_2244
The formulary is a list of all brand-name and generic drugs available in your plan. Prior authorization forms for pharmacy services can be found on the Formspage. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Anthem is a registered trademark of Anthem Insurance Companies, Inc. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Massachusetts, Rhode Island, and Vermont. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. If you don't see your medicine listed on the drug lists, you may ask for an exception at submitmyexceptionreq@anthem.com or by calling Pharmacy Member Services at 833-207-3120. Attention Prescribing Providers with members who are enrolled in an Anthem California plan: The Prescription Drug Prior Authorization Or Step Therapy Exception Request Form must be used for all members enrolled in a California plan, regardless of residence. The formulary, also known as a drug list, for each Blue MedicareRx plan includes most eligible generic and brand-name drugs. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. That way, your pharmacists will know about problems that could occur when you're . The benefit information provided is a brief summary, not a complete description of benefits. Note: Not all prescriptions are available at mail order. gcse.async = true; In some cases, retail drugs and supplies are covered under your Part B of Original Medicare medical benefit (e.g. We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. For MRMIP and MMP: Prescriptions can be filled at more than 5,000 retail pharmacies in California and a listing of these pharmacies (pharmacy network) can be found in our provider directories. Its good to use the same pharmacy each time you fill a prescription. This group meets regularly to review new and existing drugs, and to choose the top medications for our Drug List/Formulary. If you are a member with Anthems pharmacy coverage, click on the link below to log in and automatically connect to the drug list that applies to your pharmacy benefits. Change State. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid. Clicking on the therapeutic class of the drug. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Member Service 1-800-472-2689(TTY: 711). The formulary, also known as a drug list, for each Blue MedicareRx plan includes most eligible generic and brand-name drugs. Individual 2022 Select Drug List (Searchable) | This version of the Select Drug List applies to Small Group plans if your coverage is through a Small Group employer on, and in some cases, off the exchange. Blue MedicareRx (PDP) Value Plus (PDF) and
Use this form to set up home delivery for your prescriptions. Enrollment in Blue MedicareRx (PDP) depends on contract renewal. Drugs for treatment of anorexia, weight loss or weight gain. The joint enterprise is a Medicare-approved Part D Sponsor. Sep 1, 2020 Type at least three letters and we will start finding suggestions for you. If you're not sure whether these lists apply to your plan, check with your employer or call the Pharmacy Member Services number printed on your ID card. The joint enterprise is a Medicare-approved Part D Sponsor. Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont
We do not sell leads or share your personal information. Call 1-800-472-2689 (TTY: 711). For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227. The formulary is a list of our covered prescription drugs, including generic, brand name and specialty drugs. That means we use a balanced approach to drug list/formulary management, based on a combination of research, clinical guidelines and member experience. For medicines that need preapproval, your doctor will need to call 844-336-2676 Monday through Friday from 8 a.m.-7 p.m. MedImpact will review the request and give a decision within 24 hours. The latest developments and submission guidelines from around the world are considered when developing and maintaining the drug list/formulary. Simply take your written prescription to a plan pharmacy or ask your doctor to call it in. IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem. One of these lists may apply to you if your plan includes the PreventiveRx benefit (members can receive certain preventive drugs at low or no cost). We may immediately remove a brand name drug on our Drug List if we
Call to speak with a licensed insurance agent and find plans in your area. 2022 Part D Formulary (List of Covered Drugs) Register on our website to choose to receive plan communications by email or online. 634-0920-PN-CONV. Non-prescription drugs (also called over-the-counter drugs). Formularies 2023 FEP Blue Focus Formulary View List 2023 Basic Option Formulary View List 2023 Standard Option Formulary View List Drug tiers All the drugs we cover are carefully selected to provide the greatest value while meeting the needs of our members. Small Group 2023 Select Drug List (Searchable) | (PDF) Small Group 2022 Select Drug List (Searchable) | (PDF) Espaol. Here are some reasons that preapproval may be needed: For medicines that need preapproval, your provider will need to call Provider Services. View a summary of changes here . Rele nimewo Svis Manm nan ki sou kat Idantitifkasyon w lan (Svis pou Malantandan Rele 1-800-472-2689 TTY: 711 ). In Connecticut: Anthem Health Plans, Inc. Off-label drug use, which means using a drug for treatments not specifically mentioned on the drugs label. In Kentucky: Anthem Health Plans of Kentucky, Inc. We offer an outcomes-based formulary. Blue Cross and Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Contact Anthem Blue Cross and Blue Shield. Contact the Pharmacy Member Services number on your ID card if you need assistance. MA-Compare: Review Changes in each 2021 Medicare Advantage Plan for 2022, Find a 2022 Medicare Part D Plan (PDP-Finder: Rx Only), Find a 2022 Medicare Advantage Plan (Health and Health w/Rx Plans), Q1Rx 2022 Medicare Part D or Medicare Advantage Plan Finder by Drug, Guided Help Finding a 2022 Medicare Prescription Drug Plan, Search for 2022 Medicare Plans by Plan ID, Search for 2022 Medicare Plans by Formulary ID, 2022 Medicare Prescription Drug Plan (PDP) Benefit Details, 2022 Medicare Advantage Plan Benefit Details, Pre-2020 Medicare.gov Plan Finder Tutorial, Example: AARP MedicareRx Preferred (PDP) Formulary in Florida, Learn more about savings on Pet Medications, ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom], ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA], Acamprosate Calcium DR 333 MG tablets [Campral], ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3], ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels], ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine], ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera], ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER, ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL, ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL, ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA], ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb], ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB, ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB, ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate], ALENDRONATE SOD 70 MG/75 ML SOLUTION [Fosamax], ALENDRONATE SODIUM 10 MG TABLET [Fosamax], ALENDRONATE SODIUM 35 MG TABLET [Fosamax], ALENDRONATE SODIUM 70 MG TABLET [Fosamax], AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic], Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10], Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5], AMLODIPINE BESYLATE 10 MG TABLET [Norvasc], AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc], AMLODIPINE BESYLATE 5 MG TABLET [Norvasc], AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel], AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel], AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel], AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel], AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel], AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel], AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR], AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR], AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR], AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR], AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge], AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge], AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge], AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge], AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin], AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin], AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin], AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin], AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin], AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin], AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil], AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox], AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil], Ampicillin 1000 MG / Sulbactam 500 MG Injection, Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS, Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE, APOMORPHINE 30 MG/3 ML CARTRIDGE [Apokyn], Apraclonidine 5 MG/ML Ophthalmic Solution, ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt], ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt], ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris], ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris], ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris], ASPIRIN-DIPYRIDAM ER 25-200 MG CPMP 12HR [Aggrenox], ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz], ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz], ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz], ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT), ATOMOXETINE HCL 10 MG CAPSULE [Strattera], ATOMOXETINE HCL 100 MG CAPSULE [Strattera], ATOMOXETINE HCL 18 MG CAPSULE [Strattera], ATOMOXETINE HCL 25 MG CAPSULE [Strattera], ATOMOXETINE HCL 40 MG CAPSULE [Strattera], ATOMOXETINE HCL 60 MG CAPSULE [Strattera], ATOMOXETINE HCL 80 MG CAPSULE [Strattera], ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron], Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone], AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax], AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax], AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak], AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak], AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak], AZITHROMYCIN I.V. gcse.type = 'text/javascript'; Drugs on the formulary are organized by tiers. Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and
If prior authorization is required, providers must get approval from MedImpact before a prescription can be filled. ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. You must continue to pay your Medicare Part B premium. Blue Shield of Vermont.
You may ask us to cover a Medicare Part D medication not listed on our formulary by requesting a formulary exception to waive coverage restrictions or limits on your medication. : , . Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an Anrufen1-800-472-2689(TTY: 711 ). You pay nothing for these drugs and supplies covered under your Original Medicare medical benefit. All drugs on the formulary are covered, but many require preapproval before the prescription can be filled. Use the Drug Pricing Tool to price the medications you are currently taking and see which Blue MedicareRx plan is best for you. TTY users should call, 1-800-325-0778; or your state Medicaid Office. are the legal entities which have contracted as a joint enterprise with the Centers
SM, TM Registered and Service Marks and Trademarks are property of their respective owners. For more information, contact the plan. To request a printed copy of our pharmacy directory call us, 24 hours a day, 7 days a week. 2023 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/30/2022. Blue MedicareRx covers most Part D vaccines at no cost to you (and for our Value Plus plan, even if you haven't paid your deductible). Our. There is a generic or pharmacy alternative drug available. or union group and separately issued by one of the following plans: Anthem Blue
Blue MedicareRx (PDP) is accepted coast-to-coast at national pharmacy chains and grocery retailers, plus thousands of community-based independent pharmacies. Anthem MediBlue Rx Plus (PDP) (S5596-057-0) Benefit Details. Products & Programs / Pharmacy. This plan covers select insulin pay $35 copay. The Anthem HealthKeepers Plus plan also covers many over-the-counter (OTC) medicines with a prescription from your doctor. Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at, Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the. Drugs on the formulary are organized by tiers. Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Registered Marks, TM Trademarks. To help ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate. Last Updated: 03/01/2023. '//cse.google.com/cse.js?cx=' + cx; : Nu quy v n.i Ting Vit, c.c dch v h tr ng.n ng c cung cp cho quy v min ph.. Gi cho Dch v Hi vi.n theo s tr.n th ID ca quy v Cuc gi 1-800-472-2689(TTY: 711 ). Attention Members: You can now view plan benefit documents online. : . Using the A to Z list to search by the first letter of your drug. ATTENTION : si vous parlez franais, des services dassistance linguistique sont disponibles gratuitement. Compare Anthem Part D Plans MediBlue Rx* Standard Part D Plan This plan is a good choice if you take fewer medications. Call 1-800-901-0020 (TTY 711). You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. 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