Anthem | New Regulations Impact Groups with Pharmacy Coverage

Several states, including Florida, Arkansas, Oklahoma, Tennessee, and West Virginia, have introduced regulations that may impact members with pharmacy coverage and pricing arrangements with Anthem or CarelonRx.

The mandated changes apply to claims processed by pharmacies in these states and members residing in these states regardless of where the plan and, in some instances the pharmacy, is located.

Client impact:

As a result of the regulation, pricing arrangements will be adjusted for impacted member claims as follows:

West Virginia

• NADAC + $10.49 Dispense Fee
• $1.50 per prescription fee*

Florida

• AWP Pass Through pricing
• $1.50 per prescription fee*

Arkansas

• NADAC + Dispense Fee
• $1.50 per prescription fee*

Oklahoma

• AWP Pass Through pricing
• $1.50 per prescription fee*

Tennessee high-volume pharmacies

• AWP Pass Through pricing
• $1.50 per prescription fee*

Tennessee low-volume pharmacies (less than 65K claims)

• NADAC + Dispense Fee
• $1.50 per prescription fee*

Claims processed in West Virginia, Arkansas, and Tennessee low-volume pharmacies will no longer be reflected in Pricing Guarantees and NADAC pricing will be applied. For all other states, the claims will not be removed from network Pricing Guarantees.

Member impact:

In addition, the following changes have been made for pharmacy claims in these states. These changes do not impact plan design for other members.

• If members are not allowed to have higher retail cost shares as compared to prescriptions filled through home delivery, possible retail cost share changes may apply.
• For the member claims impacted, mandatory mail will not apply. Members will have a 90-day retail pharmacy option. This does not apply to Arkansas residents.
• For the member claims impacted, exclusive specialty pharmacy arrangements will not apply. This does not apply to Arkansas residents.
• Rebate guarantees (if applicable) will not be affected. Point of Sale Rebates will apply to claims in West Virginia and Arkansas.

We continue to assess solutions to address the regulations while preserving value to your clients’ plans. We will keep you up to date on any additional changes and impacts to your groups’ plan designs for members in impacted states.

_{*$1.50 if the contract does not already have a per-prescription fee for pass-through claims}