CurrentAnthemPolicy N/A

National Direct Plus Drug List - Non-formulary medications and preferred alternatives

This document lists medications that are not included on the Anthem National Direct Plus Drug List (formulary) grouped by therapeutic class and provides preferred alternative medications that are on the formulary; it also describes the prior authorization/exception process for medications not on the list and points members/providers to online and phone resources.

Policy Summary

PayerAnthem

PolicyNational Direct Plus Drug List - Non-formulary medications and preferred alternatives

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf covered alternatives are not appropriate, the prescriber must submit a prior authorization/exception request via Member Services phone or online tools; include required clinical justification and consider electronic submission for faster processing.

POLICY UPDATE CHANGES

No material clinical or coverage changes

manyTherapeutic classes with exclusions listed

numerousSpecific non-formulary medications listed

numerousPreferred alternatives provided

manyMapped Excluded Medications

Coverage summary

This document lists medications not included on the Anthem National Direct Plus Drug List, grouped by therapeutic class, with preferred alternatives and the exception/prior authorization process. Coverage stance: mixed.

The National Direct Plus Drug List is an open formulary with some closed classes. It is curated through a Pharmacy & Therapeutics process that considers effectiveness, safety, therapeutic class similarity, and affordability. Brand drugs may be excluded when generics are available.

National Direct Plus Drug List: Anthem's formulary of prescription medications approved for coverage; an open drug list with some closed classes.

Preferred alternative: A medication on the National Direct Plus Drug List recommended when a non-formulary medication is excluded.

Exception / Prior authorization process & provider requirements

Exception / Prior Authorization Process

When a medication is not on the National Direct Plus Drug List, coverage may be obtained via an exception (prior authorization) if covered alternatives are not appropriate.

Physician must contact Member Services using number on member ID card or log in at anthem.com/ca and choose Tools & Resources to download and submit the prior authorization form

Physicians may submit prior authorizations electronically for faster processing and possible real-time approval

Members/providers should check anthem.com/ca Prescription Benefits for up-to-date formulary, dosage/strength options, and any restrictions such as quantity limits, prior authorization or step therapy requirements

Prior Authorization

Prior authorization/exception required for non-formulary drugs

If the covered alternative options are not right for the member, the prescriber must submit a prior authorization/exception request via Member Services phone or online tools; electronic submission may yield real-time approval.

Documentation Required

Check formulary restrictions and documentation

Providers should verify formulary status, quantity limits, step therapy, and prior authorization requirements and include required clinical justification when requesting exceptions.

Provide clinical justification when requesting an exception
Verify any quantity limits, step therapy requirements, and prior authorization rules on the formulary

Common questions

Q: What if a medication isn't on the National Direct Plus Drug List? A: If covered alternative options are not appropriate, prescribers can request an exception/prior authorization by calling Member Services or submitting online/electronically.

Q: Where can members find the most up-to-date formulary information? A: Members should log in at anthem.com/ca and choose Prescription Benefits or call Pharmacy Member Services using the number on their ID card.

Background

Background: The National Direct Plus Drug List is curated through a Pharmacy & Therapeutics process that evaluates a drug’s effectiveness, safety, similarity within a therapeutic class, and affordability. It is an open formulary but contains some closed classes; brand products may be excluded when generic versions are available.

Scope and audience: This policy lists medications that are not included on the Anthem National Direct Plus Drug List (formulary), grouped by therapeutic class, and provides preferred alternatives that are on the formulary. It also describes the prior authorization/exception process for medications not on the list and directs members and providers to online and phone resources for formulary details. Intended users include prescribers, pharmacists, and members seeking information about excluded drugs and available formulary alternatives.