CurrentAnthemPolicy N/A

California DMHC National Drug Formulary (Anthem) - excluded medications and preferred alternatives (partial)

This document describes the California DMHC National Drug Formulary maintained by Anthem for California members, listing medications that are not on the formulary alongside preferred alternative medications, describing the formulary review process, and explaining prior authorization/exception request procedures.

Policy Summary

PayerAnthem

PolicyCalifornia DMHC National Drug Formulary (Anthem) - excluded medications and preferred alternatives (partial)

Policy CodePolicy N/A

Change TypeFormulary listing (excluded medications; preferred alternatives)

Effective Date

Next Review Date

Key ActionIf a member's needed medication is not on the National Drug List and alternatives are inadequate, request an exception by calling Member Services or submitting a prior authorization electronically via anthem.com/ca.

POLICY UPDATE CHANGES

No material change — the brief indicates has_material_change=false and provides no policy update items.

extensiveExcluded medications listed

manyTherapeutic classes with exclusions

multipleExamples of excluded branded products

multilingualLanguages provided

This policy covers the Anthem California DMHC National Drug Formulary. The formulary is primarily an open list but includes some closed classes and an extensive list of excluded medications with preferred alternatives identified.

Where a brand product is excluded and an FDA-approved generic is available, the generic may be on the formulary instead of the brand.

Formulary placement is determined by the P&T Committee using review criteria that evaluate efficacy, safety, therapeutic similarity, and affordability.

Formulary inclusion and exception process

Formulary inclusion/exception process

General rules and member/provider options when a medication is not on the formulary:

Formulary overview and alternatives: The National Drug List is a list of FDA-approved prescription drugs reviewed by the P&T process for efficacy, safety, therapeutic similarity, and affordability.

Preferred alternatives: If a medication is not on the National Drug List, preferred alternatives that are covered are provided in the listing; when a generic exists, the brand may be excluded while the generic is on the formulary.

Exception / prior authorization process: If covered alternatives are not appropriate for a member, providers may submit an exception request via prior authorization by calling Member Services (number on member ID) or submitting electronically through anthem.com/ca (Tools and Resources).

Electronic submissions may have shorter processing times and possible real-time approvals.

Plan-specific limits and member documents: Members should consult their Certificate/Evidence of Coverage or Summary Plan Description for plan-specific limits, exclusions, and coverage details.

Prior Authorization

Prior authorization / exception request required for non-formulary medications

If the member's needed medication is not on the National Drug List and alternatives are inadequate, the physician may request an exception by calling Member Services or submitting the prior authorization form via anthem.com/ca; electronic submissions may enable faster, possibly real-time, approval.

Call Member Services or submit electronically via anthem.com/ca
Electronic submissions may enable faster/real-time approval

Documentation Required

Consult Certificate/Evidence of Coverage for plan limits

Providers should verify plan-specific coverage limitations, exclusions, quantity limits, and step therapy requirements in the member's Certificate/Evidence of Coverage or Summary Plan Description.

Documentation Required

Member language assistance / alternate formats

Providers or members may request free language assistance and alternate formats for visual impairments by calling the Member Services number on the ID card (TTY/TDD: 711).

Documentation Required

Non-discrimination / grievance filing

Members can file complaints/grievances with the plan Compliance Coordinator at the provided P.O. Box address or with HHS OCR via phone or online; contact details are provided and must be used if services were not provided.

Excluded medications (examples listed)

No CPT/HCPCS/ICD-10/NDC codes provided in this partmixed

No codes listed

This document part is a partial listing of excluded medications and their preferred alternatives; the subject indicates the list is partial and the full National Drug List contains the complete mapping of preferred alternatives.

Providers should check plan-specific documents (Certificate/Evidence of Coverage or Summary Plan Description) and the full National Drug List at anthem.com/ca for the exact covered alternatives for a given member.

If covered alternatives are not appropriate, providers may request an exception via the prior authorization process by calling Member Services or submitting electronically; electronic submissions may reduce processing time and allow possible real-time approvals.

Background & definitions

The Anthem California DMHC National Drug List is maintained as a formulary of FDA-approved prescription drugs. It is generally open but contains some closed classes and an extensive list of excluded products with identified preferred alternatives.

The Pharmacy & Therapeutics (P&T) Committee reviews drugs for placement on the list and evaluates efficacy, safety, therapeutic similarity, and affordability when determining formulary status.

National Drug List / formulary: A list of FDA‑approved prescription medications reviewed and maintained by the payer's Pharmacy & Therapeutics process, indicating covered and non‑covered drugs and preferred alternatives.

Policy Summary

PayerAnthem

PolicyCalifornia DMHC National Drug Formulary (Anthem) - excluded medications and preferred alternatives (partial)

Policy CodePolicy N/A

Change TypeFormulary listing (excluded medications; preferred alternatives)

Effective Date

Next Review Date

On This Page

OpenPayer

California DMHC National Drug Formulary (Anthem) - excluded medications and preferred alternatives (partial)

Coverage summary

Formulary inclusion and exception process

Excluded medications (examples listed)

Background & definitions

Frequently asked question

Revision history