CurrentAnthemPolicy N/A

Essential Drug List (closed formulary) — Coverage Criteria

Defines Anthem's Essential Drug List (closed formulary) detailing which prescription drugs are covered, common non‑covered drugs and preferred alternatives, and explains prior authorization/exception request process for members and providers.

Policy Summary

PayerAnthem

PolicyEssential 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 the Member Services number on the member's ID card or at anthem.com/ca when a medication is not on the Essential Drug List.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

closedformulary type

prior authaccess route

manypreferred alternatives

yesexclusions present

Coverage and Formulary Stance

Coverage stance

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Formulary coverage OR approved exception: Medication is covered if it appears on the Essential Drug List OR if a prior-authorization exception is submitted by the provider and approved.

Providers should use the Member Services phone number on the member's ID card or the online prior authorization process at anthem.com/ca to submit exception requests (electronic submission is supported).

Formulary preference / coverage implication

Coverage favors listed preferred alternatives; medications explicitly identified as 'not on the Drug List' are non-preferred and generally require an override or prior authorization.

Formulary preference logic: For a given therapeutic category, coverage favors listed preferred alternatives; medications explicitly listed as 'not on the Drug List' are considered non-preferred and require prior authorization or an approved exception for coverage.

Derived from multiple therapeutic-category entries that pair 'Medications not on the Drug List' with corresponding 'Preferred alternatives'.

The Essential Drug List is a closed formulary of prescription medications that have been reviewed by the U.S. Food and Drug Administration and vetted through Anthem's Pharmacy and Therapeutics (P&T) process for effectiveness, safety, therapeutic class similarity, and affordability. As a closed formulary, only drugs on the Essential Drug List are covered by the plan; medications not on the list are not covered unless a prior authorization/exception is requested and approved. When a brand‑name product has an available generic equivalent, the brand is typically not included on the Essential Drug List.

The policy lists numerous specific products under headings such as “Medications not on the Drug List” and “Common Excluded Medications at a Glance.” These listings identify agents that are considered non‑formulary in their therapeutic categories and signal that coverage for these products is generally excluded unless a prior authorization/exception is successfully obtained.

The document includes a section titled “Common Excluded Medications at a Glance” presented in alphabetical order with specific examples. Entries include items such as Florafol FE Pediatric Solution, Lopressor 12.5 mg Tablet, prednisone dr., Zonisade, Fulphila, Lumryz, Prezcobix, Ztlido, Fylnetra, Mavyret, Prilosec Packet, topiramate 50 mg sprinkle capsule, Gammagard/SD, Pulmicort Flexhaler, tramadol 75 mg tablet, and many others. This alphabetical list functions as a quick reference of commonly excluded products.

What Providers and Members Must Do

Prior Authorization

Prior authorization required to request an exception

Prior authorization (exception) is required when a medication is not on the Essential Drug List. Providers must call the Member Services number on the member's ID card or use anthem.com/ca (Tools & Resources → prior authorization form) to submit an exception request. Electronic submission is available and may provide faster or real‑time decisions.

Call Member Services number on member ID card to request prior authorization
Submit prior authorization form via anthem.com/ca → Tools & Resources
Electronic prior authorization submission may reduce processing time and allow real‑time approval

Prior Authorization

Prior authorization expected when non‑formulary agents are requested

Medications not listed on the Essential Drug List are identified in the drug-mapping excerpts; coverage typically requires using listed preferred alternatives or obtaining prior authorization to cover a non‑listed agent.

Non‑listed drugs are mapped with preferred alternatives by therapeutic class
Coverage generally requires trial of preferred/formulary alternatives or an approved prior authorization

Note

Prior authorization not always restated in list excerpts

Some source excerpts are drug lists and mappings that do not explicitly state a prior authorization requirement for every entry. When the excerpt contains only a list or mapping, follow the general rules: check the Certificate/Evidence of Coverage or submit a prior authorization if coverage is needed.

Drug-list excerpts may not repeat prior authorization language — verify via member materials or Member Services
If in doubt, submit prior authorization/exception request

Denial Risk

Non‑covered medications risk

Drugs not on the Essential Drug List are not covered by the plan unless an exception is approved. Use of non‑listed medications without an approved exception may result in claim denial and member financial liability.

Non‑formulary medications = risk of non‑coverage unless prior authorization/exception is approved
Members/clinicians should pursue prior authorization or prescribe listed preferred alternatives to avoid denial

Denial Risk

Excluded medications may trigger denial

The Essential Drug List includes a "Common Excluded Medications" listing. Requests for coverage of medications appearing on excluded lists may be denied unless a documented medical necessity and approved exception are provided.

Presence on Common Excluded Medications at a Glance indicates likely denial without exception
Documented clinical rationale is required when requesting coverage for excluded products

Denial Risk

Grievance risk for failure to provide services

If members believe required language assistance or disability accommodations were not provided, they may file a complaint/grievance. Follow the grievance instructions in member materials or contact the Compliance Coordinator or HHS Office for Civil Rights as provided.

File a complaint with Compliance Coordinator (address provided in source)
Or file with U.S. HHS Office for Civil Rights (phone and web links provided in source)
Grievance may be filed for failure to provide language or disability services

Prior Authorization

How to request an exception / prior authorization

To request an exception/prior authorization, providers must call the Member Services number on the member’s ID card or log in at anthem.com/ca and choose Tools & Resources to download and submit the prior authorization form. Electronic submission is supported and encouraged for faster processing.

Phone: Member Services number on member ID card (TTY/TDD: 711 for language/access requests)
Online: anthem.com/ca → Tools & Resources → prior authorization form
Electronic prior authorization submission available

Documentation Required

Documentation required when requesting excluded medications

When requesting coverage for medications that are excluded or not on the Essential Drug List, include supporting clinical documentation explaining why preferred alternatives are not appropriate and the medical necessity for the requested drug.

Provide clinical rationale and relevant medical records when submitting an exception request
Reference preferred alternatives listed in the drug mapping and explain why they are unsuitable

Step Therapy

Step/therapeutic substitution guidance

Preferred alternatives are listed by therapeutic class throughout the drug mappings, implying a step or therapeutic substitution approach. Providers are expected to consider formulary-preferred agents (step therapy) before requesting coverage for non‑listed medications.

Review preferred alternatives by class before prescribing a non‑formulary agent
Documentation should explain prior trials of preferred agents when applicable

Note

Language & accessibility assistance

Members who need language assistance or alternative formats for documents should call the Member Services number on their ID card (TTY/TDD: 711). Free language assistance and disability‑related aids and services are available.

Call Member Services on ID card for free language assistance and interpretation (TTY/TDD: 711)
Request alternate formats for visual impairments via the customer service telephone number on the back of the ID card

Preferred Alternatives and Initial Therapy

Preferred alternatives for initial therapy

When a medication is listed as not on the Drug List, a named preferred alternative is provided and is the recommended initial therapy option.

Use preferred alternative: Prescribe a listed preferred alternative as initial therapy when available; if the member cannot use the preferred alternative, the provider must submit a prior authorization request for the non‑listed medication.

Examples in the document: immune serums not on the Drug List (e.g., Gamastan, Gammagard/SD) list preferred alternatives such as Cutaquig, Gamunex-C, Hizentra, Octagam, Xembify; impotence agents not on the Drug List (e.g., Stendra, vardenafil) list preferred alternatives sildenafil citrate and tadalafil.

Step Therapy and Required Trials

Therapeutic category / example non‑listed agent	Preferred alternative(s) / guidance
ALS AGENTS — Radicava (edaravone) IV / suspension
Preferred alternative: riluzole (tablets). Preferred alternatives are listed and may be required prior to exception approval.
Analgesics — butalbital‑containing products (e.g., Allzital; butalbital‑acetaminophen 50‑300mg tablet; butalbital‑acetaminophen‑caffeine 50‑325‑40mg)
Preferred alternatives: butalbital‑acetaminophen 50‑325mg tablet; butalbital‑acetaminophen 50‑300mg capsule; other butalbital‑acetaminophen formulations except 50‑325‑40mg capsule.
Bronchodilator agents — Incruse Ellipta, Tudorza Pressair (anticholinergic bronchodilators)
Preferred alternatives: Atrovent; Spiriva Respimat; tiotropium bromide.
Inflammatory conditions — multiple biologics not on the Drug List (examples: Abrilada; Actemra; adalimumab biosimilars; Bimzelx; Cimzia; Cosentyx IV; Hulio; Kineret; etc.)
Preferred alternatives: Cosentyx SC; Dupixent; Enbrel; Entyvio; Humira; Orencia SC; Otezla; Rinvoq; Selarsdi; Simponi/Aria; Skyrizi; Stelara/Ustekinumab; Tremfya; Xeljanz/XR.
Infliximab products — Renflexis; Inflectra; Zymfentra
Preferred alternatives: Avsola; infliximab; Remicade.
Migraine products — Onzetra; Reyvow; Symbravo; Tosymra; Treximet; Zembrace
Preferred alternatives: almotriptan; eletriptan; naratriptan; rizatriptan (tablet/ODT); sumatriptan (tablet/nasal/injection); zolmitriptan (tablet/ODT/nasal).
Steroid inhalants/combinations — Airsupra; Alvesco; Asmanex HFA/Twisthaler; Dulera; Pulmicort Flexhaler
Preferred alternatives: Breo Ellipta (brand and generic); budesonide‑formoterol; fluticasone furoate; fluticasone propionate; fluticasone‑salmeterol; Qvar Redihaler; Trelegy.
NSAIDs — examples of non‑listed: Cambia; Combogesic; diclofenac potassium 25mg; Elyxyb; fenoprofen; ibuprofen 300mg tab/susp; Meloxicam Susp; Zipsor
Preferred alternatives: celecoxib; diclofenac potassium 50mg; diclofenac sodium; etodolac; flurbiprofen; ibuprofen (except 300mg); indomethacin capsule; meloxicam tablet; nabumetone; naproxen tablet; oxaprozin; piroxicam; sulindac.

Coverage implication	Provider action / prior authorization expectation
Medications listed as 'not on the Drug List' are not formulary‑preferred and are generally excluded from coverage unless an exception is approved.
Providers should request a prior authorization (exception) when prescribing a non‑listed medication; documentation should justify medical necessity and why preferred alternatives are unsuitable.
Preferred alternatives are named for many non‑listed agents (therapeutic/step approach implied).
Members are expected to try listed preferred alternatives prior to coverage of non‑listed medications; if alternatives are inappropriate or ineffective, submit prior authorization/override for review.
Failure to use preferred alternatives or obtain prior authorization may result in non‑coverage or denial.
Use the Member Services number on the member ID card or the payer's prior authorization process (online/electronic submission supported) to request exceptions.

Key Terms

inv-21: Essential Drug List

DefinitionA closed formulary listing prescription medications covered by the plan; only prescription drugs on the Essential Drug List will be covered and medications not on the list require a prior authorization/exception for coverage.

Evaluation processDrugs on the list have been reviewed by Pharmacy & Therapeutics (P&T) considering effectiveness, safety, therapeutic-class similarity, and affordability.

Brand/generic policyBrand-name drugs with a generic equivalent are typically not included on the Essential Drug List (brand alternatives may be excluded when a generic exists).

Where to view listMembers can view and search the complete Essential Drug List by logging in at anthem.com/ca and choosing Prescription Benefits or calling Member Services at the number on their ID card.

inv-22: Essential Drug List

Formulary preferenceThe Essential Drug List identifies preferred medications by therapeutic class; agents not on the list are labeled 'Medications not on the Drug List' and preferred alternatives are provided (e.g., impotence agents: preferred sildenafil or tadalafil vs. non-listed vardenafil/Stendra).

Preferred alternatives exampleImmune serums not on the list (Gamastan, Gammagard/SD, Gammaked, Gammaplex) list preferred alternatives such as Cutaquig, Gamunex-C, Hizentra, Octagam, Xembify.

Coverage implicationUse of non-listed agents may require prior authorization or trying a listed preferred alternative for coverage to be granted.

inv-23: Essential Drug List — Essential Drug List

PurposeThe Essential Drug List is a formulary of drugs considered essential for coverage and management, organized by therapeutic category with mappings and alternatives.

Common excluded medicationsThe document includes 'Common Excluded Medications at a Glance' listing many specific products (alphabetical excerpts shown in the source).

Mapping and equivalentsEntries map drug names and variants and show alternative/formulary equivalents (numerous examples of mapped drug names and variants appear in the list).

Policy Background

The Essential Drug List is an FDA-reviewed, P&T‑vetted closed formulary designed to promote clinical effectiveness, patient safety, therapeutic class consistency, and cost management. Because it is closed, coverage is limited to drugs on the list and non‑listed products are expected to have cost‑effective alternatives (brand alternatives, generic equivalents, or OTC options) or require a submitted and approved prior authorization/exception for coverage.

Policy Summary

PayerAnthem

PolicyEssential 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 the Member Services number on the member's ID card or at anthem.com/ca when a medication is not on the Essential Drug List.

SourceLink

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