CurrentAnthemPolicy N/A

Anthem Diabetes Medication Preferred Drug List (PDL) guidance

Guidance on preferred vs nonpreferred diabetes medications, pharmacy claim impacts, prior authorization and step therapy requirements, and insulin quantity limits for Anthem Blue Cross and Blue Shield HP patients on nonpreferred products. Affects prescribing providers and pharmacists serving Anthem members.

Policy Summary

PayerAnthem

PolicyAnthem Diabetes Medication Preferred Drug List (PDL) guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage on the Anthem Preferred Drug List (PDL) and preferentially prescribe PDL-preferred diabetes agents to avoid pharmacy claim rejections.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 ml/30 daysinsulin quantity limit

quarterlyPDL subject to change

requiredmetformin step therapy

Formulary Coverage & Access Requirements

Formulary Coverage and Access Requirements

Coverage and pharmacy processing guidance for diabetes medications on the Anthem Preferred Drug List (PDL).

PDL verification and preference: Prescribers should preferentially prescribe PDL-preferred diabetes agents to avoid pharmacy claim rejections; verify coverage by reviewing the Anthem Preferred Drug List (PDL), which is updated quarterly.

Supported by provider guidance to avoid claim rejection

Step therapy requirement: All anti‑diabetic agents require step therapy through metformin unless contraindicated.

Metformin first‑step requirement applies to all antidiabetic agents

Prior authorization and additional step‑therapy requirements may apply to select products; obtain prior authorization where required per the PDL.

PA may be required for select products as indicated on the PDL

Policy Summary

PayerAnthem

PolicyAnthem Diabetes Medication Preferred Drug List (PDL) guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage on the Anthem Preferred Drug List (PDL) and preferentially prescribe PDL-preferred diabetes agents to avoid pharmacy claim rejections.

SourceLink

On This Page

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What Prescribers & Pharmacists Must Do

Denial Risk

Pharmacy claim rejections may occur for

Anthem Blue Cross and Blue Shield HP patients on nonpreferred products may experience a pharmacy claim rejection. To avoid delays or claim denials at the point of sale, consider prescribing preferred products when clinically appropriate.

Affected members: Anthem HP members
Action: Prescribe preferred products when possible to reduce pharmacy claim rejections

Prior Authorization

Prior authorization and step therapy may apply

Prior authorization and step therapy may apply to select preferred products. Verify coverage and any utilization management requirements before prescribing.

Prior authorization and step therapy may apply to some preferred products
Check for PA/step therapy requirements before prescribing

Step Therapy

Metformin first‑step requirement

All anti‑diabetic agents require step therapy through metformin unless metformin is contraindicated. Confirm the member has tried and failed or is intolerant to metformin per the plan's step‑therapy rules before initiating other agents.

Metformin first‑step requirement applies to all anti‑diabetic agents unless contraindicated
Document contraindication or intolerance to metformin when applicable

Note

Verify coverage by reviewing the Preferred Drug List (PDL)

Coverage should be verified by reviewing the Preferred Drug List (PDL) on the Anthem provider website. The PDL is updated quarterly; check the PDL for current preferred products, prior authorization and step therapy details.

Review the Anthem Preferred Drug List (PDL) on the provider website: https://providers.anthem.com/new-york-anthem-provider/resources/pharmacyinformation
PDL updated quarterly — verify current status before prescribing

Clinical & Policy Context

This document lists Anthem PDL categories for multiple diabetes drug classes. For insulins, examples of nonpreferred short‑acting agents include Afrezza, Apidra, Fiasp, Humalog, Novolog and branded/authorized generic aspart products; intermediate‑acting nonpreferred products include Humulin R/Novolin R and Humulin N/Novolin N; nonpreferred long‑acting products include Lantus, Levemir, Toujeo, Tresiba and Semglee. Preferred insulin examples include Admelog, authorized generic lispro, Basaglar and listed insulin glargine alternatives. Mix products (e.g., Humalog Mix, Humulin Mix, Novolog/insulin aspart mixes) are also listed.

For GLP‑1 receptor agonists, listed nonpreferred agents include Adlyxin, Bydureon, Byetta, Tanzeum and Victoza, plus the lixisenatide/insulin glargine combo Soliqua; preferred GLP‑1 agents include Trulicity and Ozempic. The document also lists formulary distinctions for other classes: DPP‑4 inhibitors (nonpreferred: alogliptin, Nesina, Onglyza, Tradjenta; preferred: Januvia), SGLT2 inhibitors (nonpreferred: Farxiga, Invokana, Steglatro; preferred: Jardiance), and TZDs (nonpreferred: Actos, Avandia; preferred: generic pioglitazone and pioglitazone combination products).

Preferred vs Nonpreferred & Definitions

Preferred vs Nonpreferred — PDL agent categories

Preferred — Examples (insulins)Admelog; Basaglar; Humulin R; Novolin R; Humulin N; Novolin N; Trulicity; Ozempic

Nonpreferred — Examples (insulins)Afrezza; Apidra; Fiasp; Humalog; Novolog; Lantus; Levemir; Toujeo; Tresiba; Semglee (listed as both in places)

Preferred vs Nonpreferred purposeLists reflect Anthem PDL placement to guide prescribing and avoid pharmacy claim rejections; verify current status on the Anthem PDL (updated quarterly)

Insulin quantity limit (definition)

DefinitionInsulin quantities are limited to 30 ml per 30 days.

ScopeLimit applies to all insulin product types referenced in the Hot Tip (short‑acting, intermediate, long‑acting, mixes)

Related requirementAll anti‑diabetic agents require step therapy through metformin unless contraindicated (see PDL/authorization guidance)

49502-0250-80	NDC listed in insulin product group
49502-0393-80	NDC listed in insulin product group
49502-0394-75	NDC listed in insulin product group
49502-0196-71	NDC listed in insulin product group
49502-0196-75	NDC listed in insulin product group
49502-0195-80	NDC listed in insulin product group

OpenPayer

Anthem Diabetes Medication Preferred Drug List (PDL) guidance

Formulary Coverage & Access Requirements

Codes and Quantity Limits

What Prescribers & Pharmacists Must Do

Clinical & Policy Context

Preferred vs Nonpreferred & Definitions