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Prescription Benefits 2005

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Frequently Asked Questions

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PDF of this booklet

Temporary ID card for $900 Deductible Plan (PDF)

Temporary ID card for PPO Plus Plan (PDF)

Anthem Rx Mail Order and Claim Forms

Prescription Drug Coverage Overview of Changes for $900 Deductible and PPO-Plus Participants

Effective January 1, 2005

Contents:
Introduction | Getting Assistance | Identification Cards | Retail Pharmacy Network | Mail Service Pharmacy Option | Prescription Transition Issues | Pharmacy Safety and Quality Programs | Questioning Coverage Decisions | New Drug Benefit Exclusion Period | Pharmacy Copayments | Preferred Drug List (Formulary) | Specialty Medications - Anthem Rx Direct Specialty | Web Site | Complaints and Appeals | Out-of-Network Pharmacy Claims

Introduction

As the result of a recently legislated Indiana Aggregate Prescription Purchasing Program (IAPPP), Indiana University will offer pharmacy benefits for its PPO plans through Anthem Prescription Management effective January 1, 2005. Anthem Prescription is an affiliate of Anthem Blue Cross and Blue Shield. The changes outlined in this booklet apply to both the IU PPO $900 Deductible Healthcare plan and the IU PPO-Plus Healthcare plan.

This booklet provides important information that will be needed by Indiana University employees enrolled in these PPO plans in order to access prescription benefits during the new plan year.   Features of the PPO prescription benefits beginning January 1, 2005 include:

• Retail prescription services (up to a 30 day supply) through an expanded network of pharmacies including most national chains and some independent pharmacies;
• Mail order prescription delivery (up to a 90 day supply) through Anthem Rx Direct;
• Copays for retail and mail order prescriptions that remain the same as in 2004. The plan will include a formulary (a list of preferred drugs), but it will not be applied to prescription copays until 2006;
• Anthem's Pharmacy Safety and Quality Programs, as described in this booklet will apply, including Step Therapy, Prior Authorization, Quantity Limits, and other requirements that may need to be met before certain drugs are covered under the plan;
• Biotech drugs and specialty medications will be provided through Anthem Rx Direct Specialty rather than BioScrip.

Getting Assistance

Customer Service can assist with a wide range of services, including answering questions about prescription benefits, helping to find participating pharmacies, providing directions on how to initiate mail order pharmacy services and how to file prescription claims. To contact Customer Service, please either:

• Call the Customer Service number on the back of your health plan ID Card - 800-345-2460, or
• Send a question via a secure online form located on the Anthem web site at www.anthem.com.   In order to use this feature, you must first register with the Anthem web site.

Customer Service is available during normal business hours from 9:00 a.m. until 5:00 p.m., Monday through Friday, Eastern Time.

Identification Cards

All employees enrolled in an IU-sponsored PPO plan will receive a new identification card from Anthem that includes both medical and prescription pharmacy benefit program information. (There will not be a separate ID card for prescription benefits.) An example of the IU PPO $900 Deductible plan card is shown below; the pharmacy information for the IU PPO-Plus and Retiree plan will be the same as the PPO $900 Deductible plan, but those cards will have copays and deductibles for each plan.

When in need of pharmacy services, present your new identification card, along with your prescription, to a participating network pharmacy provider. Claims are submitted electronically by the pharmacy.   You will only be required to pay the applicable copayment at the time the prescription is dispensed.

While we are optimistic that employees will receive these identification cards before the end of the year, it is possible that December holiday demands on the U.S. Postal Service could delay their arrival until early January. Employees who have not received their identification cards by January 1, 2005 may still begin using their benefits. In the event that you do not have a new identification card on January 1, you may obtain retail prescription benefits by giving the pharmacist your name, date of birth, and the Anthem Benefit Identification Number for Indiana University - 610575. Mail order prescription refills do not require an identification card.

Retail Pharmacy Network

Over 50,000 chain and independent retail pharmacy providers participate in the Anthem Rx Pharmacy Network. There are more than 1,000 retail pharmacy providers in Indiana alone. Among the participating pharmacy chains are:

Other independent pharmacies may also participate in the retail pharmacy network. To find a pharmacy near you, visit the Anthem web site at www.anthem.com. Select ‘Find a Doctor,’ then under National Directories select ‘Find a Network Pharmacy Near You,’ enter your zip code and ‘Search.’ If you do not have access to the Internet, you can contact Anthem Customer Service by calling the number listed on the back of your identification card - 800-345-2460 - for a list of local pharmacies.

When in need of pharmacy services, present your new identification card, along with your prescription, to a participating network pharmacy provider. Claims are submitted electronically by the pharmacy. You will only be required to pay the applicable copayment at the time the prescription is dispensed. Since the retail network includes most pharmacies, most of your retail benefits will be processed as an in-network benefit. If you should obtain a prescription from an out-of-network pharmacy that cannot process your prescription benefits online, the process for submitting manual claims is detailed later in this booklet.

Transferring prescriptions between retail pharmacies:
If you have refills left on a prescription at a retail pharmacy and wish to transfer the prescription to a different retail pharmacy, take your prescription bottle to the new pharmacy or call the new pharmacy with the information from the bottle. The new pharmacy will make the necessary calls to transfer your prescription.

Mail Service Pharmacy Option

Beginning January 1, 2005 the prescription mail service available to participants of the IU PPO $900 Deductible plan and the IU PPO-Plus plan is Anthem Rx Direct. Anthem Rx Direct is a mail service pharmacy owned and operated by Anthem. The mail service benefit is designed for plan participants who need maintenance medications for conditions such as asthma, diabetes, high blood pressure, arthritis, hormone replacement, and others.

Anthem Rx Direct offers plan participants several important benefits:

• The convenience of having prescriptions delivered directly to the home, office or anywhere in the United States
• The convenience of a higher days supply of drugs - up to a 90-day supply,
• Savings on copayments - you pay two retail copays for up to a three month supply

Anthem Rx Direct generally recommends that the initial orders for any maintenance medicine be filled through a retail pharmacy until the dosage can be stabilized. Once stabilized, Anthem Rx Direct is recommended for maintenance refills.

Anthem Rx Direct offers plan participants four convenient options for refilling mail prescription orders:

• By mail: Participants complete and return the refill envelope included with each previously filled prescription order.
• By phone: Participants call Anthem Rx Customer Care at 800-962-8192, Monday through Friday, 8:30 a.m. to Midnight Eastern time, or Saturday, 9:00 a.m. to 7:00 p.m. Visa, Master Card or Discover Card are accepted on telephone refill orders.
• By an automated telephone line: Participants can place refill orders 24 hours a day once their credit card number is entered into the Anthem Rx system. They simply select the "automated voice response unit" selection at 800-962-8192. They are then prompted to enter their prescription number(s) and credit card information to complete the order using their telephone key pad.
• By internet: Participants can log onto www.anthem.com to place requests for order refills, track the status of an order and review the Anthem formulary by drug name or therapeutic class.

For additional information about prescription benefits, participants may call an Anthem Rx Customer Care professional at 1-800-962-8192 Monday through Friday, 8:30 a.m. to Midnight, or on Saturday and Sunday from 9:00 a.m. to 7:00 p.m.

An automated telephone service is convenient for participants using Anthem Rx Direct. They may call 24 hours a day for refills or to check the status of their orders. During business hours, speaking to a Customer Care Professional is also an option.

Obtaining refills on existing mail order prescriptions:
If you currently use mail service through ScripSolutions and have refills left on your prescriptions, it is anticipated that your prescription information will automatically transfer to Anthem Prescription after January 1, 2005. This will mean that in most cases, Anthem Rx Direct will be able to handle your refill prescriptions without any interruption to you. To get your prescription refilled follow these steps:

• Call Anthem Rx Direct at 800-962-8192
• Provide your prescription information and designate your payment preferences; if you wish to pay by check rather than credit card you will be given directions on how to submit payment
• Allow at least 15 business days for processing and delivery.

Remember, even if you have refills remaining, controlled substance products and specially mixed medications like compounds cannot be transferred automatically. In these situations, you will need to obtain a new prescription from your physician. Also note that internet refills cannot be accepted for first time refills on transferred prescriptions.

While both Anthem and ScripSolutions are optimistic about Anthem receiving the electronic files needed to automatically transfer prescription information from ScripSolutions to Anthem, it is possible that the data transfers will be delayed or unsuccessful. In this event, you will need to obtain new prescriptions and submit them as a new prescription order.

Placing orders for new prescriptions:
For new mail pharmacy orders, customers must first contact their prescriber for a new prescription, written for a 90-day supply. They then complete an easy order form and send it to Anthem Rx Direct with their original prescription and appropriate copayment. For your convenience, a mail order form is included with this booklet.

Transferring a prescription from a retail pharmacy to Anthem Rx Direct:
Anthem offers a help desk (888-613-6091, Monday through Friday, 8 a.m. to 6p.m. Eastern Time) for first-time users to ease the transition from retail to mail. This help desk assists customers in converting their maintenance medication prescriptions from a retail pharmacy to the Anthem Rx Direct mail service pharmacy. Customers can call the help desk, provide key personal and medical provider information, as well as details about the prescription(s). The Anthem Rx Direct Customer Service representative then contacts the customer’s physician(s) to secure prescriptions written for the maximum days supply allowed by the customer’s pharmacy benefits. After receiving the new prescriptions, Anthem Rx Direct dispenses the customer’s medications and ships them to the address provided during the initial telephone call. Please allow time for processing and delivery of your prescription. The time required will depend on how quickly your physician’s office responds to Anthem’s request.

Getting refills of prescriptions filled by Anthem Rx Direct:
The customer can call 1-800-962-8192 Monday through Friday, 8:30 a.m. to Midnight, or on Saturday and Sunday from 9:00 a.m. to 7:00 p.m. for personal service from a Customer Care professional or to use the 24-hour automated refill service. Prescription numbers (from prescription labels) are entered using the key pad on the telephone. A credit card that has previously been used by Anthem Rx is required.

Checking the status of an order:
The member calls 800-962-8192 and enters their identification number. Simply follow the voice prompts to check the status of the order.

Prescription Transition Issues

In anticipation of the transition to Anthem, the university is encouraging individuals who have existing maintenance prescriptions to obtain a refill from ScripSolutions before January 1, 2005. Doing so will help ensure that the customer has their medication on hand during the first weeks of January. The university has worked with ScripSolutions to make refills available after only half of the most recent prescription has been used. In addition, the employee may check with their pharmacist to see if an early refill option is available to them.

Remember, you do not need a new identification card in order to obtain prescription benefits. At a retail store, give the retail pharmacist your name, date of birth, indicate that your benefits are administered by Anthem effective January 1 and that your Benefit Identification Number (BIN) is 610575. (A temporary prescription benefit card with the BIN number will be available on the University Human Resource Services Web page www.indiana.edu/~uhrs for those who wish to print it.) No identification card is needed for mail order prescriptions.

Pharmacy Safety and Quality Programs

Anthem administers a number of programs that are designed to help ensure the safe use of prescription medications. From time to time, your physician may prescribe a medication that is subject to the Anthem Pharmacy and Therapeutics Committee’s approved Clinical Program guidelines. Prior Authorization, Quantity Limits, Dose Optimization and Step Therapy are edits recommended by Anthem’s National Pharmacy and Therapeutics Committee. In order to give customers time to consult with their physician, Step Therapy edits will not apply until February 1, 2005. Other clinical edits (Prior Authorization, Quantity Limits, and Dose Optimization) will become effective January 1, 2005.

Step Therapy
This program means that you may need to use one or more medications before benefits for the use of another medication can be covered. Step Therapy is typically required for drugs that are over prescribed based upon manufacturer or FDA approved uses or taken for non-FDA approved or unproven uses. Your pharmacist will receive an electronic message at the point of sale notifying them that Step Therapy is required.

Step Therapy edits at the point-of-sale are designed to help:

• encourage utilization of prescription benefits in accordance with nationally recognized standards
• promote the use of recognized prescribing guidelines
• support access to high quality, yet cost-effective prescription drug benefits

Prior Authorization
Prior Authorization is the process of verifying medical necessity before a request for prescription benefits is approved. The Prior Authorization process is normally used to monitor the prescribing of certain drugs in order to promote access to safe and cost effective prescription benefits. When your physician has prescribed a medication for you that requires a Prior Authorization, your pharmacist will receive an electronic message at the point of sale. Your pharmacist has the ability to call Anthem directly for benefit approvals on some medications which require prior authorization. In some cases, Anthem may need to contact your physician before benefit approval can be given.

Quantity Limits
This is a limit on the amounts of a medication that you can obtain benefits for during a specific period of time for one copay. Most often, Quantity Limits are set on a monthly basis.

Dose Optimization
This program, sometimes called dose consolidation, normally involves the conversion from a twice daily dosing schedule to a once daily dosing schedule based upon manufacturer recommended use. A once-a-day dosing schedule may increase compliance and decrease expenses for you and your health plan. As always, you should consult with your physician to determine what is appropriate for you. If your physician feels that medical reasons exist for you to take these medications more than once a day, a letter of medical necessity will be necessary in order for you to access your prescription benefits.

The following information is designed to help you determine which edits or guidelines apply if your physician prescribes any of the medications listed below. The same information, plus clinical criteria for prior authorizations, is available on the Anthem Web page www.anthemprescription.com. Inclusion on this list does not mean that the drug is covered under the IU PPO health care plans. Check your PPO plan booklet for coverage.

> View the List of Drugs and Associated Safety and Quality Edits

Questioning Coverage Decisions

If you do not agree with a pharmacy benefit determination regarding Prior Authorizations, Step Therapy, Quantity Limits or other prescription clinical edits, you may address your issue through Anthem's complaint and appeal process described later in this booklet.

New Drug Benefit Exclusion Period

The FDA approves drugs every year, some of which receive approval in less than six months.   During this time of increased approvals, several products have been recalled from the market and some products have required relabeling due to potentially serious adverse effects.   Following the trend in the healthcare marketplace, Anthem has adopted a waiting period for coverage of newly approved pharmaceutical products.   This exclusion applies for the first six months after the date the product or technology receives FDA approval.   Medications currently affected by this policy include

• Campral   (exclusion expires 1/29/2005)
• Cymbalta (exclusion expires 2/4/2005)

Pharmacy Copayments

The pharmacy benefits for both IU PPO plans include four copayment tiers.   These 2005   copays are the same as in 2004 .

Preferred Drug List (Formulary)

A preferred drug list, also commonly referred to as a formulary, is a list of prescription medications selected for their quality, effectiveness of treatment, and in certain situations cost. Anthem uses a carefully selected list of drugs--the Anthem National Formulary-- to help ensure that customers have access to quality, cost-effective medications. The Anthem National Formulary includes hundreds of brand name and generic medications.

Under the state prescription purchasing program, both of Indiana University's PPO plan's pharmacy benefits will include the Anthem National Formulary, but it will not be fully implemented until January 1, 2006.  This means that for 2005, copays for prescriptions will remain the same as in 2004; brand copays will continue to be based on the costs of the drug (under $60 or $60 and over). When the formulary is fully implemented in 2006, copays will be based on the formulary status of each prescription. Generic drugs will continue to have the lowest copay, brand name drugs on the formulary will have a mid-level copay, and drugs not on the formulary will have the highest copay. During 2006 Open Enrollment, employees will receive additional information about the formulary and any associated changes in copayments.  

Specialty Medications - Anthem Rx Direct Specialty

Beginning January 1, 2005, IU employees currently obtaining specialty medications (for example, Remicade, Enbrel, Avonex, Prograf, Rebetrol) through ScripSolutions's BioScrip program can obtain these medications through Anthem Rx Direct Specialty. To start receiving a specialty prescription, you or your doctor may call 800-870-6419, Monday-Friday 9 a.m. to 5 p.m., and a benefit specialist will assist you. When you use Anthem Rx Direct Specialty mail order service instead of using a retail pharmacy or medical benefits, you will have no copay for your specialty prescription.  

Web Site

The Anthem web site contains a number of tools that may help you increase the value of your health benefits. Customers can have easy access to both the health and pharmacy benefits with a single registration and sign on. This allows you to view all your health and pharmacy benefits history together without having to log in twice or go to more than one website. Customers simply enter the site at www.anthem.com.

Interactive Formulary - The interactive formulary, which lists medications alphabetically or by therapeutic class, allows visitors to access, print, or download the entire listing in various formats.   In addition, this interactive tool allows detailed searches by drug name, therapeutic class, major and minor categories, and formulary alternatives.

Pharmacy Locator - This search tool shows detailed information on each of the retail pharmacies participating in Anthem's Preferred Network. Users can search by pharmacy name, city, state, and zip code.   Results include the name of the pharmacy, its complete address, telephone and fax numbers, and the hours of operation.

Drug Database - From www.anthem.com, users can search the interactive database to retrieve useful information such as: drug name and uses, manufacturer recommended dosing, possible side effects, and potential dangerous drug interactions.

Refill Request - After entering the secure section of www.anthem.com, participants can review all prescriptions available for refill and select which prescriptions they wish to order. Orders are dispensed via the Anthem Rx Direct Network Mail Service Pharmacy and delivered directly to the customer, alleviating the need to visit a pharmacy in person or make a phone call.

Status Review - Plan participants can receive shipping and tracking information on Anthem Rx Direct Mail Service Orders. This function shows the status of all orders placed in the last 30 days. It also provides the dates the order was received and shipped, the shipping address, shipping method, and tracking numbers.

Prescription History and Online Explanation of Benefits - Anthem currently provides a prescription history and explanation of benefits capability through the secure customer portal at www.anthem.com.   The Prescription History contains 15 months of data including:

If at any point the customer desires to see the explanation of benefit form, simply click on the "select" button next to the prescription description and they will have access to Customer Paid, Plan Paid, Total Cost of the Drug, Copay, and any deductibles applied

Order Form - Plan participants can download a printable version of the Anthem Rx Direct order form in order to mail in prescription refill requests.

Medical and Health Information - The site provides several links to medical and health information sites for visitors to research physical conditions and drug treatments.

Online Shopping - The online shopping function provides direct access to Anthem services, such as the ability to request refills and retrieve shipping and tracking information on Anthem Rx Direct Mail Service Orders. Also available online are detailed pages on the features of the mail service, how to order via telephone and mail, and an online order form, which can be printed and used to mail in prescription refill requests.

FAQs - Content is included to provide helpful answers to frequently asked questions. Three sections are provided that focus on the Anthem Rx Direct Mail Service, the Anthem Rx Network of Retail Pharmacies, and the Anthem Rx Clinical and Formulary Services. In addition to FAQs, a complete healthcare glossary is included.

Complaints and Appeals

In order to help ensure that members' rights are protected, all participants in Anthem-administered plans are entitled to the complaint and appeal process. Complaints include any expression of dissatisfaction regarding Anthem's services, products, network provider or employees. Appeals refer to formal requests by the member (or his/her legal representative) to change a decision previously made by Anthem regarding the refusal to arrange for or pay for certain services. Procedures for registering complaints and appeals are outlined in your certificate of coverage.

Complaints
When Anthem's Member Services receive oral or written complaints, it is logged into a tracking system.   After the issue is researched, a response is provided to the member. Anthem monitors its Member Services to promote the timely resolution of member complaints.

Appeals
If a complaint is not resolved to the member's satisfaction, the member may initiate a formal appeal by contacting Anthem Member Services. The Appeals Unit then reviews all supporting documentation, with assistance from medical and/or network management if necessary. Anthem then determines whether to reverse or uphold the original decision. Following the determination, Anthem sends the member a notification of its decision. Members are advised of additional steps available to them. If a member is not satisfied with the initial appeal determination, he/she may request an additional review by an appeals panel. Members are allowed a personal appearance before the appeals panel or may participate by phone. For certain issues, an External Appeal is also available to the member when the internal appeals process is exhausted without resolution to the member's satisfaction.

At any time during the Complaint and Appeal Processes, issues involving urgently needed clinical care may be handled more quickly through an Expedited Appeal Process.

Appealing a Certification or Authorization Denial
Once you have contacted Anthem, your appeal will be reviewed by Anthem associates who were not involved in the initial denial decision. A clinical peer will be involved in the decision making.   Ultimately, if you are not satisfied with the decisions made in the appeals process, your claim may be eligible for review by an independent review organization. Your provider can also appeal denials of these types. You may want to ask your provider to initiate the appeal. Note that in situations where time is of the essence, an expedited appeal process is available when you are waiting to receive treatment pending our decision regarding benefit payment.

Appealing a Claim Payment of Denial
Once you have contacted Anthem, your appeal will be reviewed by Anthem associates who were not involved in the initial denial decision. If necessary, a clinical peer will be involved in the decision making. Ultimately, if you are not satisfied with the decisions made in the appeals process, your claim may be eligible for review by an independent review organization.

Expedited Appeals
An expedited review of your appeal is available if Anthem is informed that your medical needs require a faster turn around than our normal appeal process. Your contract or benefit book may describe the time frames for normal or expedited appeals. You can call the Member Services number on your ID card during normal business hours.

If waiting would create harm, Anthem encourages you to continue with your treatment without waiting to hear regarding benefit approval/disapproval. Keep in mind that if you are receiving treatment from a network provider, he or she is contractually obligated to use independent medical judgment in treating you. This means that network providers are required to keep your best interests in mind from a clinical perspective, regardless of whether your insurance will cover such treatment.

Out-of-Network Pharmacy Claims

Prescriptions received from participating retail pharmacy providers are submitted by the pharmacy through an online claims processing system and do not require any paperwork. Your benefit for out of network pharmacy purchases is 50% of the prescription cost. Most non-network or out-of-area pharmacies are unable to submit claims electronically. In instances where the non-network provider is unable to submit claims electronically, the customer is required to submit a Direct Member Reimbursement (DMR) claim form along with a copy of the receipt from their prescription purchase. The DMR claim form and receipts for medications must be submitted directly to Anthem at the address on the form within 60 days after the date of service and are subject to drug utilization review.

Anthem Prescription Management 
PO Box 145433 
Cincinnati, OH 45250-5433 

DMR claims are processed manually. Reimbursement checks and explanations of payment are then mailed to the customer within approximately 15 to 30 days. A DMR claim form may be downloaded from www.anthem.com, or may be requested by contacting Anthem Customer Service.

See also: Frequently Asked Questions