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1+: Anthem Benefit Change for Exclusive Specialty Pharmacy Program

Dec 18, 2015

Starting January 1, 2016, benefits for the exclusive specialty pharmacy program will move from two courtesy fills to zero courtesy fills for Small and Large Group business in California. This change will go into effect for new and renewing business at renewal.

Background on exclusive specialty pharmacy
The exclusive specialty pharmacy program requires members to use an in-network specialty pharmacy for their specialty drugs to be covered. Only about one to two percent of prescriptions filled are considered exclusive specialty drugs. This client​ flier gives you more information about the program.

Anthem's goal is to make sure members transition smoothly from a retail pharmacy to a specialty pharmacy provider for their drugs. For California members, Accredo Specialty Pharmacy is the network specialty pharmacy they need to use.

Here’s how the transition will work:

  1. When a member attempts to fill a prescription for a drug on the exclusive specialty pharmacy drug list at a retail pharmacy, Anthem sends a letter. They tell the member that for the drug to be covered, the prescription has to be moved to the specialty pharmacy, Accredo, before the next fill. They explain the benefits and how to get started. The member also gets an automated phone call as a reminder.
  2. Once Accredo receives the prescription, a specialty pharmacy associate calls the member to schedule the delivery of the medicine.

Some things to remember:

  1. This change does not impact benefits currently without exclusive specialty pharmacy (for example: ASO groups, Medicare, Medicaid).
  2. There is no change to California members who have the exclusive specialty benefit and are taking HIV medication(s). They can continue to opt-out of having to use exclusive specialty for these drugs.
  3. Contract language has also been updated and implemented as part of this change.

For questions, please ​contact a member of your b&p Sales Team - 888.722.3373.

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