On April 1, 2020, Anthem notified physicians that it will soon require that specialty pharmacy medications administered in the office or outpatient hospital setting be obtained exclusively through CVS Specialty pharmacy. The notice states that the requirement applies to Anthem’s commercial HMO effective with July 1, 2020, dates of service. However, the California Medical Association (CMA) has learned that this requirement will also extend to Anthem’s Medi-Cal Managed Care product.

This requirement applies to all specialty drugs covered through the commercial HMO and Medi-Cal managed care HMO where Anthem has financial risk for the cost of specialty medications.

For dates of services on or after July 1, 2020, providers will be required to contact CVS Specialty’s dedicated Anthem line to order specialty medications. When submitting claims, physicians should continue to bill for administration of the medication, but not bill for the medication itself. If specialty medications are obtained through other pharmacies, Anthem will deny the claim.

CMA has raised several concerns with the new CVS Specialty requirement, including but not limited to the highly sensitive nature of certain drugs and the special handling and storage required to preserve the efficacy and ensure patient safety, logistical issues in ordering and receiving the medications, and liability concerns. Additionally, it’s unclear how physicians will know if Anthem is at risk (vs. the delegated group) for the specialty drug to know if this policy applies.

CMA has requested a meeting with Anthem to discuss these concerns. Practices seeking more information on the change are encouraged to contact Anthem Provider Services at (800) 677-6669.