CurrentAnthemPolicy N/A

National Direct Preferred Drug List — medication alternatives

Defines medications that are not included on the National Direct Preferred Drug List and lists preferred alternative drugs on the formulary; applies to Anthem members and providers using the National Direct Preferred Drug List (national list with state-specific access instructions).

Policy Summary

PayerAnthem

PolicyNational Direct Preferred Drug List — medication alternatives

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request when a prescribed medication is not on the National Direct Preferred Drug List and alternatives are inappropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+therapeutic categories listed

numerouspreferred alternatives provided

multiplecommon excluded sections

web/phonemember/provider resources

5languages with assistance

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Medication alternatives listing

Covered approach — the policy lists medications that are not on the National Direct Preferred Drug List and specifies one or more formulary-preferred alternatives for each.

Formulary membership and alternatives: The document lists medications that are not on the National Direct Preferred Drug List and, for each, one or more preferred alternatives that are on the list.

Coverage of a medication not on the National Direct Preferred Drug List may require prior authorization (exception) when the preferred alternatives are not appropriate for the member.

Exclusions and limitations may apply to entries on the National Direct Preferred Drug List. For definitive information about what is covered under a member’s benefit, providers and members should check the member’s Certificate/Evidence of Coverage (EOC) or Summary Plan Description (SPD). The National Direct Preferred Drug List notes that if a medication is not on the list there are preferred alternatives on the formulary and that coverage details — including any quantity limits, prior authorization, or step therapy requirements — are available via the Prescription Benefits portal or Pharmacy Member Services on the member ID card.

The document includes a section titled Common Excluded Medications at a Glance that lists many individual products presented as not included on the National Direct Preferred Drug List. These entries are shown in alphabetical order and often pair the excluded product with a mapped alternative or indicate that the item is excluded from the national list.

Examples of medications identified in the Common Excluded Medications at a Glance section (partial, alphabetical excerpts) include: Dawnzera (mapped to Dolobid/Drizalma/Doryx MPC/Edarbyclor/Emflaza/etc.), Anzupgo, Ilumya (mapped to Injectafer/Inpefa/Iyuzeh and others), Neupogen (mapped to Novolin/Novolog/Nutropin AQ/Nucynta ER/Nypozi/olopatadine ophthalmic soln/Omnaris and others), Apidra (mapped to Novolog/Insulin Aspart products), Asmanex HFA/Twisthaler, Armour Thyroid (Evexithroid/Niva Thyroid/NP Thyroid/Renthyroid/Thyroid), Belsomra, Bepreve, Bimzelx, Bivigam, Bomyntra, Brenzavvy/Bexagliflozin, Briumvi, Brynovin, and many additional brand and generic names. The list in the source document is extensive and presented across multiple alphabetical entries; providers should consult the full National Direct Preferred Drug List for complete coverage mappings and any preferred alternatives.

Provider Actions — Prior Authorization, Step Therapy, and Denial Risk

Prior Authorization

Prior Authorization Required for Non‑Formulary Drugs

Medications not listed on the National Direct Preferred Drug List may still be covered if a prior authorization (exception) is submitted. Coverage may be denied unless a prior authorization or exception request is submitted for drugs that are not on the National Direct Preferred Drug List.

If the covered alternative options are not appropriate for the member, providers may request an exception via prior authorization.
Prior authorization requests can be submitted by calling the Member Services number on the member's ID card or by logging in at anthem.com/ca and choosing Tools & Resources to download and submit the prior authorization form.
Electronic prior authorization submission is available and may result in faster processing or real-time approval so prescriptions can be filled without delay.

Note

Prior Authorization Details Not Specified Here

This section does not list specific prior authorization codes, criteria, or detailed policy rules. Providers must refer to the member's Certificate/Evidence of Coverage, Summary Plan Description, or the full National Direct Preferred Drug List online for current PA requirements and any clinical criteria.

Denial Risk

Excluded Medications — Denial Risk

Some medications are identified as excluded or commonly excluded. Prescribing excluded medications risks claim denial unless an approved exception is obtained prior to dispensing.

'Common Excluded Medications' listed in the National Direct Preferred Drug List are at risk for denial if submitted without an approved exception.
Providers should verify coverage status before prescribing to avoid unexpected denials or member cost exposure.

Denial Risk

Potential Denial When Prescribing Excluded or Non‑Listed Medications

Prescribing a medication that is excluded or not on the formulary may result in denial at the point of pharmacy adjudication if an exception (prior authorization) has not been approved. Providers should obtain authorization prior to dispensing when possible.

If an exception is needed, submit the prior authorization request before the member attempts to fill the prescription to reduce denial and out‑of‑pocket risk.
Electronic PA submissions may allow for more rapid determinations and possible real‑time approvals.

Prior Authorization

Prior Authorization Submission Methods

Providers may submit prior authorization requests by phone, by downloading and submitting the PA form via the Anthem provider/member website, or electronically through supported ePA channels. Electronic submissions often reduce processing time.

Call the Member Services number on the member's ID card for phone PA submission.
Log in at anthem.com/ca and choose Tools & Resources to download and submit the prior authorization form.
Use electronic prior authorization (ePA) when available for potentially faster processing and real‑time approvals.

Documentation Required

Documentation to Support Prior Authorization Requests

Providers should include clinical documentation that supports medical necessity when requesting prior authorization or an exception. This section does not describe specific documentation fields; include relevant patient history, prior therapies tried and failed, and rationale for the requested medication.

Document prior use of preferred alternatives and reasons they are unsuitable for the member.
Include pertinent clinical notes, lab results, and specialty consults when applicable.

Step Therapy

Step Therapy and Other Restrictions — Check Formulary

The National Direct Preferred Drug List identifies preferred alternatives and implies step‑therapy or required use of preferred agents before coverage of non‑preferred products. Providers should check the formulary for any step therapy, quantity limits, or other restrictions that may apply.

Preferred alternatives listed indicate the likely first‑line agents for coverage; using these may avoid prior authorization or step requirements.
Check for quantity limits and step therapy rules on the online Prescription Benefits page or the Certificate/Evidence of Coverage.

Step Therapy

Preferred Alternatives Indicated but No Step‑Therapy Policy Detailed

Preferred alternatives are indicated on the National Direct Preferred Drug List, which suggests an alternative‑first approach; however, this section does not present a formal step‑therapy policy or criteria. Providers should not assume an exception will be granted without documented medical need for the non‑preferred product.

The presence of preferred alternatives implies step‑therapy may be required, but specific step counts or required prior therapies are not detailed here.
When alternatives exist, submit documentation explaining why the preferred alternative is not appropriate for the member if requesting an exception.

Step Therapy and Restriction Tables

Medication / Class	Restriction / Step therapy note	Provider action
Various non-formulary medications listed across classes (see National Direct Preferred Drug List)	Some drugs are subject to restrictions such as quantity limits, prior authorization, or step therapy; specific step rules are not provided in this excerpt	Providers should check Prescription Benefits at anthem.com/ca or call Pharmacy Member Services on the member's ID card and submit prior authorization when alternatives are inappropriate
Proton pump inhibitor brand products (e.g., Dexilant, Prevacid ODT, others)	Preferred alternatives named (esomeprazole, lansoprazole capsule, omeprazole, pantoprazole, rabeprazole); step-therapy implied but not specified	If prescribing a non-preferred PPI, confirm benefits and submit PA if member cannot use preferred alternative
Gallstone solubilizing agents (examples: non-preferred agents listed)	Preferred alternative = ursodiol (generic)	Refer to formulary preferred alternative; submit PA only if ursodiol is unsuitable

Therapeutic class / Example non‑preferred drugs	Preferred alternative(s)	Implication for step therapy
Proton Pump Inhibitors and Combinations — Dexilant, Konvomep, omeprazole‑sodium bicarbonate, Prevacid ODT, Prilosec Packet, Protonix Packet, Rabeprazole DR Sprinkle, Voquezna	esomeprazole; lansoprazole (capsule); omeprazole; pantoprazole; rabeprazole	Document names preferred agents implying a formulary preference; step‑therapy sequence not defined in excerpt
Inflammatory conditions / Biologics — multiple agents listed (e.g., Kevzara, Kineret, Olumiant, Orencia IV, Stelara, Taltz, Ustekinumab products)	Preferred alternatives include Cosentyx SC, Dupixent, Ebglyss, Enbrel, Entyvio, Orencia SC, Otezla, Rinvoq, Skyrizi, Tremfya, Xeljanz/XR	Preferred alternatives named; implies switching to listed preferred biologics before non‑preferred, but no explicit step order provided
Migraine agents (including CGRP and others) — Onzetra, Reyvow, Symbravo, Tosymra, Treximet, Zembrace, Vyepti, Zavzpret	Preferred alternatives include almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan (various formulations), zolmitriptan; CGRP alternatives: Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy	Preferred alternatives listed; providers should choose formulary agents first or seek PA when non‑preferred are clinically necessary

Excluded medication (example)	Mapped / Equivalent preferred alternative	Coverage note
Cambia (brand and generic)	Flector (brand and generic)	Cambia is listed as commonly excluded with Flector presented as the mapped preferred alternative; coverage for non‑preferred agent may require PA
Dawnzera	Dolobid	Example from 'Common Excluded Medications at a Glance' showing a mapping to a preferred alternative; providers should verify benefits before prescribing
Ilumya	Injectafer	Listed as an excluded product with an alternative mapping; prescribers should confirm formulary status and request PA if needed

Definitions and Key Terms

inv-22: National Direct Preferred Drug List — definition and scope as open formulary with P&T review

DefinitionThe National Direct Preferred Drug List is an open formulary of prescription medications reviewed by the Pharmacy & Therapeutics (P&T) process (considering effectiveness, safety, class similarity, and affordability).

ScopeIncludes a broad range of drug choices nationally; some closed drug classes and restrictions (quantity limits, prior authorization, or step therapy) may apply.

PurposeIdentifies medications on the preferred drug list and lists preferred alternatives for medications not on the list to support cost‑effective, clinically appropriate prescribing.

AccessMembers and providers can view the complete National Direct Preferred Drug List at anthem.com/ca under Prescription Benefits or call Pharmacy Member Services using the number on the member's ID card.

inv-23: 'Medications not on the Drug List' — definition for items identified as not included

Definition'Medications not on the Drug List' are products specifically identified in the National Direct Preferred Drug List as not included on the payer's direct preferred formulary.

PresentationThese medications are shown in the chart with corresponding preferred alternatives that are on the list.

Implication for coverageIf a prescribed drug is not on the list, coverage may be denied unless a prior authorization (exception) is submitted and approved or an appropriate preferred alternative is used.

inv-24: Preferred alternatives — definition for formulary-preferred agents recommended as substitutes

Definition'Preferred alternatives' are high‑quality, cost‑effective medications on the National Direct Preferred Drug List recommended in place of non‑formulary or non‑preferred drugs.

Usage guidancePreferred alternatives are listed next to medications not on the drug list to guide prescribers toward formulary options (examples: esomeprazole or omeprazole listed as preferred alternatives for Dexilant).

Formulary effectsUse of preferred alternatives may avoid prior authorization, step therapy, or other restrictions associated with non‑formulary drugs.

inv-25: Common Excluded Medications — definition and examples of commonly excluded items

Definition'Common Excluded Medications' are products presented in the National Direct Preferred Drug List as frequently excluded from coverage (listed 'at a glance' in alphabetical order).

ExamplesExamples shown in the document include many brand and generic names (partial examples across the list: Dawnzera = Dolobid; Neupogen; Ilumya; Apidra; Armour Thyroid).

Coverage consequenceMedications appearing as Common Excluded Medications are at risk for non‑coverage or denial if submitted under the associated benefit without an approved exception or appropriate alternative.

inv-26: Grievance — definition of a member complaint alleging failure to provide services or discrimination

DefinitionA grievance is a complaint filed by a member alleging failure to provide services or discrimination based on race, color, national origin, sex, age, or disability.

Language access relevanceFailure to provide required language assistance or aids/services may form the basis of a grievance.

Filing optionsMembers may file a written complaint with the Compliance Coordinator at the provided P.O. Box or with the U.S. Department of Health and Human Services, Office for Civil Rights using the contact information in the document.

OpenPayer

National Direct Preferred Drug List — medication alternatives

Coverage Criteria — Non‑Formulary Medications and Preferred Alternatives

Provider Actions — Prior Authorization, Step Therapy, and Denial Risk

Step Therapy and Restriction Tables

Definitions and Key Terms

Background — Document Purpose