CurrentAnthemPolicy N/A

Essential Direct Drug List (closed formulary) - Coverage Criteria

Defines the closed formulary Essential Direct Drug List for Anthem members and provides drugs not covered with preferred alternatives and instructions for prior authorization/exception requests. Affects prescribers, pharmacies, and plan members.

Policy Summary

PayerAnthem

PolicyEssential Direct Drug List (closed formulary) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization/exception request via Member Services phone or anthem.com/ca when a member's medication is not on the Essential Direct Drug List.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

closedformulary type

anthem.com/cawhere to view complete list

manyexamples not on list

20+language accessibility

Coverage rules and drug list scope

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Formulary coverage: Only prescription drugs listed on the Essential Direct Drug List are covered under the plan.

Closed formulary; brand-name drugs with generic equivalents generally not included. Exclusions and limitations may apply; check the member's Certificate/Evidence of Coverage or Summary Plan Description for details.

Prior authorization / exception

Exception process — prior authorization required when ALL of the following occur:

Exception/prior authorization: If a member's medication is not on the Essential Direct Drug List and available covered alternatives are unsuitable, the prescriber must submit a prior authorization (exception) request.

Submit by calling the Member Services number on the member's ID card or by logging in at anthem.com/ca (Tools & Resources) to download and submit the prior authorization form. Electronic submission is available and may allow real-time approval.

Only prescription drugs listed on the Essential Direct Drug List are covered under the plan. Drugs that are not on the Essential Direct Drug List are not covered; exclusions and limitations may apply as noted in the member’s Certificate/Evidence of Coverage or Summary Plan Description (SPD). Members and providers should check the complete list online at anthem.com/ca or call Member Services for details about covered alternatives, dosage/strength options, and any restrictions such as quantity limits, prior approval, or step therapy requirements.

This policy explicitly lists multiple individual products and brand/generic variants as Medications not on the Drug List within their therapeutic categories. Examples shown in this excerpt include hematopoietic/immune serum agents (e.g., Cinryze, Dawnzera, Orladeyo), impotence (PDE5) agents (e.g., Stendra and vardenafil), numerous inflammatory and biologic agents (e.g., Abrilada, Actemra, multiple adalimumab biosimilars), migraine CGRP agents (e.g., Vyepti, Zavzpret), multiple sclerosis agents (e.g., Bafiertam, Briumvi, Gilenya), and many others listed by class with preferred alternatives identified.

The policy includes a searchable, alphabetical cross‑reference titled Common Excluded Medications at a Glance that maps numerous branded and generic products to excluded entries in the Essential Direct Drug List. Examples from the excerpt include pairs such as Sovuna / Avtozma / Xifyrm, Azelex / Emflaza, baclofen 15mg tablet / baclofen 5mg solution mapped to excluded alternatives, and many additional entries (for instance, Bepreve, Bimzelx, Bivigam, Basaglar, Cambia, Cequa, Cinryze, etc.) shown with their corresponding excluded or alternative listings.

What providers must do / denial and exception processes

Prior Authorization

Prior authorization required for non‑listed drugs

Prior authorization is required when a prescriber requests coverage for a medication that is not listed on the Essential Direct Drug List. Providers must submit a prior authorization request by calling the Member Services number on the member's ID card, logging in at anthem.com/ca and choosing Tools & Resources to download and submit the prior authorization form, or by submitting electronically for faster processing and potential real-time approval.

Submit via Member Services phone number on member ID
Download/submit form at anthem.com/ca > Tools & Resources
Electronic prior authorization submission supported (faster processing)

Step Therapy

Non‑listed medications vs preferred alternatives

When a medication is not on the Essential Direct Drug List the plan generally directs providers to use preferred alternatives. The Essential Direct Drug List is a closed formulary — only listed drugs are covered — and preferred alternatives (brand, generic, or OTC) are identified for many therapeutic classes. Providers should review the listed preferred alternatives for the drug class before requesting an exception.

The formulary is closed: only drugs on the list are covered
Preferred alternatives (brand/generic/OTC) are identified per class (see Medication Alternatives lists in the policy)
Use of a non‑listed medication without prior authorization may result in non‑coverage

Prior Authorization

Coverage limitation for non‑listed drugs

Coverage for a non‑listed medication is limited and is granted only when an exception (prior authorization) is approved based on the information provided by the prescribing clinician demonstrating medical necessity or lack of suitable alternatives.

Coverage is limited to cases where prior authorization criteria are met
If a generic equivalent exists, brand requests are less likely to be approved

Denial Risk

Use of non‑listed medications may trigger denial

Use of a non‑listed medication without an approved prior authorization may trigger a claim denial at the point of pharmacy adjudication. Providers should obtain approval before dispensing whenever possible to avoid member liability for the drug cost.

Unapproved non‑listed drugs may be denied at claim submission
Members may be responsible for cost if claim is denied

Denial Risk

Excluded medication risk

Some medications are expressly excluded from coverage on the Essential Direct Drug List. Prescribing or dispensing excluded medications can result in claim denial and potential member cost responsibility. Providers should consult the 'Common Excluded Medications at a Glance' section for specific excluded products.

Excluded medications are not payable under the plan
Check the 'Common Excluded Medications at a Glance' lists in the policy for details

Note

Exclusion cross‑reference (Common Excluded Medications at a Glance)

See the policy's cross‑reference lists (labeled “Common Excluded Medications at a Glance” and the Medication Alternatives sections) for examples of non‑listed and excluded drugs and their preferred alternatives. These lists identify many specific products by therapeutic class and provide suggested covered alternatives.

Medication Alternatives sections (multiple class‑level lists) contain preferred alternatives
'Common Excluded Medications at a Glance' provides an alphabetical cross‑reference of exclusions

Note

How to request assistance (language/communication)

If a member or provider needs language assistance or other communication support to request a prior authorization or exception, call the Member Services number on the member's ID card. Free interpreter services and auxiliary aids are available for members with limited English proficiency or disabilities (TTY/TDD: 711).

Call Member Services on the member ID card for language or disability assistance
TTY/TDD: 711

Step Therapy

Preferred alternatives / implied step therapy

Preferred alternatives and implied step‑therapy: where preferred alternatives are listed for a therapeutic class, the plan expects providers to try those alternatives first unless there is a documented reason they are unsuitable. When step therapy is implied by the availability of preferred alternatives, documentation showing prior trials and reasons for failure or intolerance should be included with any prior authorization request.

Document prior trials of preferred alternatives and reason for failure/intolerance when requesting an exception
Failure to document use of preferred alternatives may delay or deny approval

Preferred alternatives and step requirements

Therapeutic category	Medications not on the Drug List	Preferred alternatives / guidance
ALS AGENTS	Radicava IV (Brand and Generic)/Suspension	riluzole tablet
ANALGESICS - Analgesics-Sedatives	Allzital; butalbital-acetaminophen 50-300mg tablet; butalbital-acetaminophen-caffeine 50-325-40mg capsule/solution	butalbital-acetaminophen 50-325mg tablet; butalbital-acetaminophen 50-300mg capsule; butalbital-acetaminophen-caffeine capsule/tablet (except 50-325-40mg capsule)
ANALGESICS - Nonsteroidal Anti-inflammatory Agents (NSAIDs)	Cambia (Brand and Generic); Combogesic; Coxanto (Brand and Generic); diclofenac potassium 25mg tablet; Elyxyb; fenoprofen; Fenopron; ibuprofen 300mg tab/susp; ibuprofen/famotidine; Indocin Supp (Brand and Generic); Indocin Susp (Brand and Generic); ketoprofen 25mg, 50mg capsule; lofena; meloxicam capsule; Meloxicam Susp (Brand and Generic); Naprelan (Brand and Generic); naproxen suspension; naproxen/esomeprazole; Relafen DS; Sprix; tolectin; tolmetin; Vyscoxa; Xifyrm; Zipsor (Brand and Generic)	celecoxib; diclofenac potassium 50mg tablet; diclofenac sodium tablet; etodolac; flurbiprofen; ibuprofen tablet (except 300mg); indomethacin capsule; meloxicam tablet; nabumetone; naproxen tablet; oxaprozin tablet; piroxicam; sulindac
ANALGESICS - Opioid Combinations	hydrocodone-acetaminophen solution 10-300mg; Nalocet; Oxycodone-Acetaminophen Tablet/Solution (Brand); Prolate Tablet	hydrocodone-acetaminophen tablet/solution (except 10-300mg); oxycodone-acetaminophen tablet (generic)
ANALGESICS - Salicylates	Dolobid	diflunisal
ANAPHYLAXIS THERAPY AGENTS	Auvi-Q; Neffy	epinephrine auto-injector
ANDROGENS - Anabolic	Aveed; Azmiro; Jatenzo; Kyzatrex; methitest; methyltestosterone capsule; Natesto; Tlando	testosterone enanthate injection; testosterone cypionate injection; testosterone gel/gel pump; topical solution; Xyosted
ANTIASTHMATIC AND BRONCHODILATOR AGENTS - 5-Lipoxygenase Inhibitors	zileuton ER	montelukast tablet; zafirlukast tablet
ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Adrenergic Combinations	Bevespi Aerosphere; Duaklir Pressair	Breztri (preferred alternative listed)
IMPOTENCE AGENTS - Selective cGMP PDE5 Inhibitors	Stendra (Brand and Generic); vardenafil tablet; Vybrique	sildenafil citrate (generic Viagra); tadalafil (generic Cialis)
INFLAMMATORY CONDITIONS	Abrilada; Actemra; multiple adalimumab and biologic products (see list)	Cosentyx SC; Dupixent; Enbrel; Entyvio; Orencia SC; Otezla; Rinvoq; Selarsdi; Simlandi; Simponi/Aria; Skyrizi; Tremfya; Xeljanz/XR
INFLIXIMAB PRODUCTS	Renflexis; Inflectra; Zymfentra	Avsola; Infliximab; Remicade
MIGRAINE PRODUCTS	Onzetra; Reyvow; Symbravo; Tosymra; Treximet (Brand and Generic); Zembrace	almotriptan; eletriptan; naratriptan; rizatriptan

Drug list governance and scope

The Essential Direct Drug List is maintained through Anthem’s Pharmacy & Therapeutics (P&T) process. The P&T committee reviews drugs considering effectiveness, safety, similarity within therapeutic class, and affordability. The list is a closed formulary, meaning only medications on the list are covered and brand‑name drugs with available generics are generally excluded. For details on coverage, preferred alternatives, and exception processes, providers should consult the full list online or the member’s Certificate/Evidence of Coverage or SPD.

Key definitions

Closed formulary (Essential Direct Drug List definition)

DefinitionA formulary where only the prescription drugs on the Essential Direct Drug List are covered by the plan; drugs not on the list are not covered except by an approved exception (prior authorization).

Coverage implicationBrand-name drugs with a generic equivalent available are generally not included on the Essential Direct Drug List.

AlternativesDrugs not on the list may have cost‑effective alternatives such as a preferred brand alternative, a generic equivalent, or an over‑the‑counter option.

How to view listMembers can view and search the complete Essential Direct Drug List at anthem.com/ca (Prescription Benefits) or call Member Services using the number on their ID card.

Related restrictionsInformation on dosage/strength options and any restrictions such as quantity limits, prior approval or step therapy requirements is available on the online list or Certificate/Evidence of Coverage.

Grievance / complaint

DefinitionA formal report (complaint or grievance) filed with the plan or with the U.S. Department of Health and Human Services Office for Civil Rights alleging discrimination or failure to provide required services.

When to fileIf a member believes the plan failed to provide language assistance, reasonable accommodations for disability, or discriminated based on race, color, national origin, sex, age or disability, they may file a complaint/grievance.

How to contact the planFile a written complaint to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279 or call the Member Services number on your ID card for assistance (TTY/TDD: 711).

How to file with OCRComplaints can be filed with the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201; call 1-800-368-1019 (TDD: 1-800-537-7697) or file online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

FormsComplaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.