EMPLOYEE BENEFITS / Prescription RX
Carelon RxMember Services: 833-439-1004
Pharmacy Help Desk: 833-253-4454
Specialty Pharmacy: 833-255-0645
Learn About Our Pharmacy Programs
Pharmacy Management Formulary
Learn about our comprehensive pharmacy management formulary and how it benefits you.
Pharmacy Benefits
Discover the extensive pharmacy benefits available to TCSIG members.
Pharmacy Mail Order Program
Explore the convenience of our Pharmacy Mail Order Program.
PRIOR AUTHORIZATION (PA) PROCESS
Prior Authorization (PA) is a basic component of managed care providing a control point for quality of care and cost effectiveness.
Five Basic Steps to Prior Authorization
Member
Receives a prescription drug from their doctor that requires
PA.
Provider
Notifies member that PA is required & forwards the PA form
to Anthem.
Anthem
Receives the PA request via ePA, phone, fax, or email for
processing.
CCR/Pharm Tech
Processes phone, fax, or email requests in PAHub &
advises of approval or sends to Rph for review.
Member
Receives approval for prescription drug or reasons for
denial.
Non-PA Drugs
Most prescriptions get filled right away when a member takes them to the pharmacy.
PA Drugs
However, certain drugs need to be reviewed and approved by the member's health plan before they are covered.
Prescription Co-Pay Structure
Retail Pharmacy - 31-Day Supply
Present your medical I.D. card with your prescription. The pharmacist will fill your prescription and submit your claim electronically for you. You will be charged a copay based on the following criteria:
- Generic - $5
- Preferred Brand - 25% to a maximum of $35
- Non-Preferred Brand - 45% to a maximum of $70
A covered person may elect a brand name product when a generic is available; however, the covered person will be liable for the difference in cost between the brand name and the generic drug along with the brand name copay.
A generic or formulary drug will automatically be substituted for a brand name drug unless there are health reasons and a letter of medical necessity from the prescribing physician has been received and approved by a panel of clinical pharmacists at Ingenio.
Retail Pharmacy - 90-Day Supply
- Generic - $10
- Preferred Brand - $50
- Non-Preferred Brand - $90
When the retail cost of a Preferred or Non-Preferred Brand name drug is more than $67.00, you can save money using the Retail 90-day supply program.
This program was designed for individuals using maintenance medications for long-term medical conditions. Have your doctor write your prescription for a 90-day supply with three refills, if appropriate. A covered person may elect a brand name product when a generic is available; however, the covered person will be liable for the difference in cost between the brand name and the generic drug along with the brand name copay.
A generic or formulary drug will automatically be substituted for a brand name drug unless there are health reasons and a letter of medical necessity from the prescribing physician has been received and approved by a panel of clinical pharmacists at Ingenio.
Mail Order Pharmacy - 90-Day Supply
- Generic - $10
- Preferred Brand - $50
- Non-Preferred Brand - $90
When the retail cost of a Preferred or Non-Preferred Brand name drug is more than $67.00, you can save money using the mail order pharmacy.
This program was designed for individuals using maintenance medications for long-term medical conditions.
- Have your doctor write your prescription for a 90-day supply with three refills, if appropriate.
- Complete the Order Form and Patient Profile questionnaire. The questionnaire will only need to be completed with your first order.
- Select method of payment, i.e., credit card or check. Online ordering is available after your initial order.
A covered person may elect a brand name product when a generic is available; however, the covered person will be liable for the difference in cost between the brand name and the generic drug along with the brand name copay.
A generic or formulary drug will automatically be substituted for a brand name drug unless there are health reasons and a letter of medical necessity from the prescribing physician has been received and approved by a panel of clinical pharmacists at Carelon Rx.
Savings.
Convenience.
Peace of mind.
Get it all with our home delivery pharmacy.
If one less thing to do in your day sounds good, you can get your prescription medications delivered to your home instead of picking them up at the pharmacy. It’s easy to set up home delivery for the prescriptions you take long-term for conditions like diabetes or asthma. You’ll get a 90-day supply with free standard shipping. And it may save you money.
With home delivery, you get:
Savings
Many medicines cost less when you get a 90-day supply instead of three 30-day supplies.
Convenience
You can skip the trip to the pharmacy. First-time home delivery orders take about two weeks, and refills take 3 to 5 days. You can set up automatic refills, too.
Peace of mind
You’ll be less likely to miss a dose and more likely to stay on track with the treatment your doctor prescribed.
2 easy ways to switch:
- You can get started with home delivery online at anthem.com/ca or through the Anthem Anywhere/Sydney app. Just visit the pharmacy page after you log in to get started. You can also refill your prescriptions, find a pharmacy, see what's covered and even price drugs before you get them.
- Or you can call us at the Pharmacy Member Services number on your health plan ID card.
Still have questions?
Call us at the Pharmacy Member Services number on your health plan ID card.
Exclusive Specialty Pharmacy
Extra support for your employees who use complex, high-cost medications
Drug costs continue to climb, and because pharmacy is the health benefit your employees use the most, managing those costs is vital to your bottom line. That’s especially true for specialty drugs — high-cost medications used to treat complex long-term conditions like hepatitis C, cancer, immune deficiencies, certain inflammatory conditions and multiple sclerosis. In 2017, about half of all prescription drug spending was for specialty drugs. That rate will approach 60% by 2021.
You want to make sure your employees get the best health results possible from the drugs they take. That’s where our Exclusive Specialty Pharmacy program can be a great help — providing the extra support and care they need when they’re taking specialty drugs.
Support focused on improving adherence
Our Exclusive Specialty Pharmacy program provides solutions that help your employees better
manage their health conditions by staying on track with their medications. When they stick to
their drug treatment plans, they stay healthier. And they avoid unnecessary costs that can
result from not taking their medications or not taking them correctly.
— like emergency room
visits, hospital stays and missing work. That will help you hold down overall costs.
With Exclusive Specialty Pharmacy, your employees get:
- Their medication delivered to their home or work — wherever is most convenient for them.
- Calls from the specialty pharmacy to make sure they order and get their drugs quickly.
- Clinical support, including advice from pharmacists and nurses experienced in working with complex chronic conditions and specialty drugs, who can answer their questions about side effects and other concerns.
- Educational and support programs that help them better understand their condition and encourage them to take their medications correctly.
- Help finding possible financial assistance for high-cost medications.
The high cost of non-adherence
Non-adherence — not taking medications as prescribed — has been called “the other drug
epidemic.” Each year, it causes
125,000
deaths
10% to 25% of hospital admissions
$289 billion in medical costs and lost
work
Research shows that 20% to 30% of prescriptions are never filled and
about 50% of medications for chronic disease aren’t taken as prescribed.
Support that makes a difference
In 2017, the Exclusive Specialty Pharmacy program supported 91,000 Anthem members and managed 680,000 member calls. That’s an average of:
When you consider that the average doctor’s office visit is 20 minutes long , this additional support is valuable for your employees who are managing serious long-term health conditions.
Exclusive Specialty Pharmacy — your employees’ experience
Employees who take specialty drugs are required to get them through IngenioRx specialty pharmacy.
When they go to their local retail pharmacy to fill a prescription for one of these drugs, it won’t be covered.
They’ll get a phone call from IngenioRx within 48 hours, telling them about how the Exclusive Specialty Pharmacy program works and how to fill their prescriptions. They’ll get a follow-up letter, too.
Once the specialty pharmacy gets the prescription, they’ll call your employee to set up delivery and make sure they know all about the drug and any potential side effects. They’ll also provide expert storage and handling to make sure the drugs are delivered safely, plus any supplies your employee needs to take the medicine.
Your employees will have 24/7 access to extra support managing their condition.
Want to learn more about how Exclusive Specialty Pharmacy can support your employees and help you manage costs? Reach out to your Anthem representative.