cammp.css

Pharmacy Benefits

Getting Your Medicine

Anthem Blue Cross Cal MediConnect works with many pharmacies in Santa Clara County. And we cover a wide range of brand-name and generic drugs.

Need a prescription filled?

Bring your Anthem Blue Cross Cal MediConnect card and your prescription to a network pharmacy. You can also use a network mail-order pharmacy.

See what drugs we cover

2019 Formulary List-Updated as of 6/1/2019

Need a printed copy of the Formulary (Drug List)?

Call Member Services at 1-855-817-5785 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. Pacific time to ask us to mail you a formulary. You can order by phone whether or not you’re already a member.

If you’re already a member, you can email us at DirectoryRequest_MMP@anthem.com to ask for a printed formulary. When you email us, we’ll call you to verify your membership so we send you the right formulary.

Don’t see your medication on the Drug List?

You may be able to keep taking the medicine you take now for a while. Read about our transition plan here.

Find a pharmacy in our network
Mail-order pharmacy

As an Anthem Blue Cross Cal MediConnect Plan member, you can get prescription drugs shipped directly to your home through Express Scripts, Inc., our network mail-order pharmacy program.

To get order forms and information about filling your prescriptions by mail, call Express Scripts Mail Order department at 1-866-830-3883 (TTY 711) 24 hours a day, 7 days a week or visit Express Scripts Website

Express Scripts, Inc. Home Delivery Pharmacy Order Form

You can expect to receive your drugs within 14 days after you place your order. If your mail-order drugs do not arrive within 14 days, you should call Member Services at 1-855-817-5787 (TTY 711).

As a member, you may be able to sign up for automated mail-order delivery of all new prescriptions at any time by calling 1-866-830-3883 (TTY 711) 24 hours a day, 7 days a week or going to http://www.express-scripts.com.

File an appeal or grievance

For more information about how to ask for coverage determinations and submit grievances and appeals, see Chapter 9 in your Member Handbook (Evidence of Coverage) or call Member Services.

To get the status of your request, call Member Services.

Grievances:

What is a grievance?

A grievance is a type of complaint that does not involve the denial of payment, or denial or discontinuation of services by our health plan or our network providers.

You might file a grievance if you have a problem with things such as:

  • You feel you are being encouraged to leave your plan
  • Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room
  • The way your doctors, network pharmacists or others behave
  • Not being able to reach someone by phone or get information you need
  • A problem with customer service
Who can file a grievance?

You may file a grievance. Or, someone else may file the grievance for you with your permission.

Appointing a representative

If you want someone else to file the grievance for you, fill out the Appointment of Representative form and send it to us with your grievance.

.A legal surrogate under court order or state law may also be able to file an appeal. Examples of a legal surrogate may include a legal guardian or an individual acting under a power of attorney.

When can a grievance be filed?

You can make the complaint at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about.

When will the health plan respond?

We have thirty (30) days from the filing date to respond to a standard grievance.

Expedited grievances

You may only ask for a “fast” (expedited) grievance under certain circumstances. You have the right to an expedited grievance if you ask for a “fast” coverage determination or “fast” appeal and we decide that the “fast” decision you requested should be processed under the standard timeframe. You will be notified in writing if you have the right to a “fast” grievance.

Where can a grievance be filed?

File grievances in writing to:

Mail a written appeal to:
Anthem Blue Cross Cal MediConnect Plan Medicare Complaints, Appeals and Grievances
Mailstop: OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040

File grievances over the phone by calling Member Services at 1-855-817-5785 (TTY 711).

Appeals:

What is an appeal?

An appeal is when you ask us to review a decision we made about coverage of a Part D prescription drug or the amount you must pay for the coverage.

You might file an appeal if:

  • We refuse to cover or pay for a Part D prescription drug you think we should cover
  • We turn down your request for an exception to cover a prescription drug
  • You disagree with the amount you must pay for cost-sharing for a Part D prescription drug
How and when can an appeal be filed?

You may file an appeal within 60 calendar days of the date on the letter we sent to tell you of our decision. You might be able to file an appeal even if 60 days have passed since we made our first decision. Tell us in your written request why you could not file within the 60 days allowed.

Your prescribing doctor or other prescriber can make an appeal for you. Someone other than your prescriber can also make an appeal for you, but they must first complete an Appointment of Representative form. If you want someone else to file an appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

Where can an appeal be filed?
  • Mail your written appeal to:

    Anthem Blue Cross Cal MediConnect Plan Medicare Complaints, Appeals and Grievances
    Mailstop: OH0205-A537
    4361 Irwin Simpson Road
    Mason, OH 45040

  • Call Member Services at 1-855-817-5785 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m.
  • Fax your written appeal to 1-888-458-1406.

You can get help from the Health Insurance Counseling and Advocacy Program

You can also call the Health Insurance Counseling and Advocacy Program (HICAP). The HICAP counselors can answer your questions and help you understand what to do to handle your problem. HICAP is not connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. The local HICAP phone number is 1-408-350-3200.

Getting help from Medicare

You can call Medicare directly for help with problems. Here are two ways to get help from Medicare:

  • Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY: 1-877-486-2048. The call is free.
  • Visit the Medicare website (www.medicare.gov).

You can get help from the California Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-855-817-5785 (TTY: 711) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

Who can file an appeal?

Your prescribing doctor or other prescriber can make an appeal for you. Someone other than your prescriber can also make an appeal for you, but they must first complete an Appointment of Representative form. If you want someone else to file an appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

Fast (expedited) appeals

You or your prescribing doctor or other prescriber can ask for a fast (expedited) appeal if you are asking about a drug you have not yet received and waiting on a decision on a standard appeal could cause serious harm to your health or hurt your ability to function.

When will I receive a decision
  • Expedited (Fast) Part D Prescription Drug Appeal: 72 hours
  • Standard Part D Prescription Drug Appeal: 7 calendar days (pre-service appeals) or 14 calendar days (payment appeals)
Appointing a representative

If you want someone else to file the appeal for you, fill out the Appointment of Representative form and send it to us with your appeal.

A legal surrogate under court order or state law may also be able to file an appeal. Examples of a legal surrogate may include a legal guardian or an individual acting under a power of attorney.

What do I include with my appeal?
  • Your completed Redetermination Request Form
  • Your name, address and member ID number
  • Any information or evidence (documents, medical records) to support your appeal
  • An Appointment of Representative (AOR) form may be required if a person other than you or your prescribing physician is appealing on your behalf
What can I do if the appeal decision is unfavorable?

If we don’t decide in your favor, we’ll send you a letter to tell you. You will have to reach out directly to the Independent Review Entity (IRE) at this stage of the process.

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Ave., Suite 703
Pittsford, NY 14534-1302
Fax number: 1-585-425-5390
Customer Service: 1-585-348-3400

How we make decisions

H6229_19_38074_U CMS Accepted 01/01/2019 Page Last Updated On 06/05/2019

Quality Assurance and Utilization Management
Initiatives designed to improve quality, prevent over- and under-utilization and reduce costs.

Learn More