CurrentAnthemPolicy N/A

California DMHC Essential Alternatives Drug List (Español) pdf opens in a new window

A closed formulary (Essential Alternatives Drug List) for Anthem California per CA DMHC: lists prescription drugs that are excluded from the essential list and provides preferred alternative medications and high-level instructions for members and prescribers about exceptions/prior authorization processes and where to find current formulary information.

Policy Summary

PayerAnthem

PolicyCalifornia DMHC Essential Alternatives Drug List (Español) pdf opens in a new window

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a needed medication is not on the Essential Alternatives Drug List, the prescriber must submit a prior authorization request by calling Member Services on the member ID card or by submitting the prior authorization form at anthem.com/ca (Tools & Resources).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported.

manyListed Excluded Medications (document part 1 examples)

manyPreferred Alternatives Listed (document part 1 examples)

closedFormulary Type

extensiveDrug pairs listed in part

multilingual

Coverage Summary & Scope

This document is Anthem California’s California DMHC Essential Alternatives Drug List, a closed formulary that lists FDA‑approved prescription medications that are excluded from the essential list and identifies clinically preferred, lower‑cost alternative medications.

The formulary was developed through the Pharmacy & Therapeutics (P&T) process to provide covered alternatives for medications that are not on the Essential Alternatives Drug List. If a needed medication is not on the list, prescribers may request an exception via prior authorization by calling Member Services or submitting the prior authorization form at anthem.com/ca; electronic prior authorization submissions are available and may process faster or in real time.

Members and providers should consult the member’s plan Certificate/Evidence of Coverage (SPD) or anthem.com/ca (Prescription Benefits) for plan‑specific dosing, concentration options, and restrictions such as quantity limits, prior authorization, and step therapy.

General Coverage Rules and Exception Process

Covered when ALL of the following are met:

Closed formulary: The plan is a closed formulary: only medications on the Essential Alternatives Drug List are covered.
From plan description: the Essential Alternatives Drug List is a closed formulary; drugs not on the list are generally not covered.
Exception / prior authorization process: If a medication is not on the Essential Alternatives Drug List, prescribers may request an exception via prior authorization by calling Member Services or submitting the prior authorization form at anthem.com/ca (Tools & Resources).
Describes how prescribers request exceptions/authorizations.
Electronic prior authorization submissions are available and may have faster processing and potential real-time approval.
Electronic submissions may process faster and sometimes be approved in real time.
Where to find dosing/quantity/step-therapy details: Members should consult anthem.com/ca (Prescription Benefits) or their Certificate/Evidence of Coverage (SPD) for details on dosing/concentration options and restrictions (quantity limits, prior authorization, step therapy).
Members directed to website or plan documents for coverage details and restrictions.

Formulary Listings — Excluded and Preferred Alternatives (examples)

Preferred / Alternative Medications (examples by therapeutic category provided in document part 1)mixedCovered

	riluzole tablet (ALS alternative to Radicava)
	butalbital-acetaminophen 50-325mg tablet; butalbital-acetaminophen 50-300mg cap; butalbital-acetaminophen-caffeine capsule/tablet (except 50-325-40mg) (sedating analgesics alternatives)
	celecoxib; diclofenac potassium 50mg tablet; diclofenac sodium tablet; etodolac; flurbiprofen; ibuprofen tablets (except 300mg); indomethacin capsule; meloxicam tablets; nabumetone; naproxen tablets; oxaprozin tablets; piroxicam; sulindac (NSAID alternatives)
	fentanyl patch; hydromorphone ER; hydrocodone bitartrate ER tablet; levorphanol 3mg tablet; morphine sulfate ER; oxymorphone ER; tramadol tablet (except 75mg); tramadol ER; xyvona 3mg (opioid alternatives)
	hydrocodone-acetaminophen tablet/solution (except 10-300mg); oxycodone-acetaminophen tablet (generic) (opioid combo alternatives)
	diflunisal (salicylate alternative)
	epinephrine auto-injector (anaphylaxis agent alternative to Auvi-Q/Neffy)
	testosterone enanthate injection; testosterone cypionate injection; testosterone gel (multiple topical forms); Xyosted (androgen alternatives)
	buspirone; lorazepam (anxiolytic alternatives)
	montelukast tablet; zafirlukast tablet (5-lipoxygenase inhibitor alternatives)

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Common Excluded Medications - Quick Alphabetical Lookups (document part 1 examples)mixedNot Covered

	Cipro HC (Brand and Generic)
	Gemtesa
	methitest tablet/methyltestosterone capsule
	Qnasl/Child
	Trulance
	Citalopram Capsule
	Gilenya
	methocarbamol 1000mg/tanlor
	Qsymia (Brand and Generic)
	Tryptyr

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Actions for Prescribers & Providers

Prior Authorization

Prior authorization required for non‑formulary medications / exceptions

If a needed medication is not on the Essential Alternatives Drug List, the prescriber must submit a prior authorization request by calling Member Services on the member ID card or by submitting the prior authorization form at anthem.com/ca (Tools & Resources). Electronic submissions are available and may process faster or in real time.

Documentation Required

Consult plan documents for coverage details

Providers should direct members to their Certificate/Evidence of Coverage (SPD) or anthem.com/ca Prescription Benefits for details on dosing/concentration options and restrictions (quantity limits, prior authorization, step therapy) as coverage is limited to listed medications.

Definitions & FAQs

Essential Alternatives Drug List: A closed formulary listing prescription drugs covered by the plan; drugs not on the list are generally not covered but may have preferred alternatives or be eligible for an exception via prior authorization.

Q: What if a medication is not on the Essential Alternatives Drug List? A: Prescribers may request an exception / prior authorization by calling Member Services or submitting the prior authorization form at anthem.com/ca; electronic submissions may process faster and sometimes in real time.

Q: Where can members view the most up-to-date list and restrictions? A: Members should log in to anthem.com/ca and select Prescription Benefits or call Member Services; the plan Certificate/Evidence of Coverage (SPD) contains plan‑specific limitations and exclusions.

Clinical Evidence & Rationale

The P&T rationale for developing the Essential Alternatives Drug List considered efficacy, safety, therapeutic similarity to other drugs in the same class, and affordability when selecting excluded products and preferred alternatives.

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