Yes, Anthem Blue Cross does cover prescriptions on virtually every plan it sells, whether you get coverage through an employer, the ACA marketplace, Medicaid, or a Medicare Advantage plan. What changes from plan to plan is which drugs are on the covered list, how much you pay at the counter, and which pharmacies you can use. The pieces below walk through how to check your own coverage and what to expect when you fill a prescription.
Finding Out What Your Plan Covers
Every Anthem pharmacy benefit is built around a formulary, also called a drug list. It’s the catalog of FDA-approved brand-name and generic medications your plan will pay for, organized by therapeutic class, with notes on any extra steps a drug requires.
Different Anthem plans use different formularies. Employer plans may run on lists labeled Essential, National, National Direct, or Traditional Open. State Medicaid plans each keep their own Preferred Drug List. Medicare Advantage plans use yet another formulary. A drug covered under one Anthem plan may not be covered under another, so checking the specific list tied to your plan matters.
Three ways to look up a drug:
- Log in at anthem.com or through the Sydney Health app and open your plan’s drug list. It’s searchable and downloadable as a PDF.
- Use the Price a Medication tool on the website or app, which compares generic and brand options and surfaces available discounts.
- Call the Pharmacy Member Services number printed on the back of your insurance ID card.
Your Certificate of Coverage or Summary Plan Description spells out the exclusions and limits in writing.
What You’ll Pay
Anthem organizes covered drugs into tiers. Lower tiers carry lower out-of-pocket costs. Exact copays vary by plan, but one employer plan offered through the City of San Diego illustrates a typical structure:
- Tier 1a lower-cost generics: $5 for a 30-day retail supply, $12.50 for a 90-day home delivery supply.
- Tier 1b other generics: $15 for 30 days, $37.50 for 90 days.
- Tier 2 preferred brand-name drugs: $30 for 30 days, $90 for 90 days.
- Tier 3 non-preferred or specialty drugs: $50 for 30 days, $150 for 90 days.
- Tier 4 specialty drugs: 30% coinsurance, capped at $250 per prescription.
Anthem’s Medicare Part D formulary uses a five-tier design, where preferred generics can run as little as $1 to $4 for a one-month supply during the initial coverage stage.
One rule catches people by surprise. Many Anthem plans apply a Preferred Generic policy: if you ask for a brand-name drug when a generic version is available, you may owe the generic copay plus the price difference between the two drugs. That price difference generally does not count toward your plan’s annual out-of-pocket maximum.
On individual and marketplace plans, prescription costs typically count toward the overall out-of-pocket maximum rather than a separate pharmacy cap, and some commonly prescribed medications are available at $0.
Where You Can Fill Your Prescription
Anthem’s pharmacy network includes more than 67,000 pharmacies nationwide, split into two levels. Level 1, or preferred, pharmacies include about 26,000 locations such as CVS, Target, Kroger, Walmart, Albertson’s, Giant Eagle, and Costco. Filling at these spots usually means lower copays. Level 2 pharmacies, more than 40,000 of them, are still in-network but typically cost more. Going out-of-network means paying the in-network copay plus a significant share of the remaining allowed amount.
If you take a maintenance medication for a condition like diabetes, asthma, or high cholesterol, Anthem requires you to use the Rx Maintenance 90 network for 90-day supplies. You can get those either at participating retail pharmacies such as CVS or through home delivery from CarelonRx Pharmacy, Anthem’s pharmacy benefit manager.
Home delivery through CarelonRx ships up to a 90-day supply with free standard shipping. First-time orders generally take about five days to process; refills take around two days, with standard shipping arriving in three to five days. Pharmacists are available by phone, text, or chat around the clock. You enroll by logging into the Anthem website or Sydney Health app, going to the prescriptions section, and switching to CarelonRx Pharmacy.
Rules That Can Delay or Block a Fill
Even when a drug is on your formulary, Anthem may apply utilization management rules before paying for it. The formulary’s Notes column shows which rules attach to a given drug.
- Prior authorization: your prescriber has to get advance approval from Anthem. Common for drugs with high misuse potential, narrow approved uses, or lower-cost alternatives.
- Step therapy: you have to try one or more alternative medications first. If those don’t work, the plan may then cover the originally prescribed drug.
- Quantity limits: a cap on how much of the drug you can get in a month.
- Age limits: coverage restricted based on your age.
- Dose optimization: switching from multiple lower-strength doses to a single higher-strength dose.
Specialty medications have their own layer of rules. Drugs on Anthem’s Exclusive Specialty Drug List must be filled through a participating specialty pharmacy. Anthem partners with BioPlus Specialty Pharmacy across plan types, including Medicaid. Anthem also keeps a Specialty Drug Benefit Exclusion List of medications not covered under the pharmacy benefit, though exceptions can be requested.
How Coverage Differs by Plan Type
Employer-sponsored plans show the widest variation. Your employer chooses the formulary, the network, and the copay structure. Some plans include a PreventiveRx benefit that covers certain preventive medications at low or no cost.
Marketplace plans bought through the ACA exchange cover most generics and many brand-name drugs, with costs based on tier. Pharmacy deductibles and out-of-pocket maximums vary.
Medicaid plans are the most generous on cost-sharing and vary by state. Virginia Medicaid and FAMIS members pay no pharmacy copay at all. Nevada Medicaid charges no copay for drugs on the Preferred Drug List when a doctor writes the prescription. Indiana plans range from no copay to $4 for preferred drugs and $8 for nonpreferred drugs. All Anthem Medicaid plans cover many over-the-counter medications when accompanied by a prescription, and all use CarelonRx.
Medicare Advantage plans from Anthem generally bundle Part D drug coverage into the package. Anthem does not offer standalone Medicare Part D plans as of 2026. The formulary uses five tiers, and the Part D coverage gap has been eliminated as of January 2025; beneficiaries pay $0 for covered drugs after reaching the $2,100 out-of-pocket limit. Insulin on Medicare Advantage plans is capped in 2026 at the lowest of $35 per month, 25% of the maximum fair price negotiated under Medicare, or 25% of the negotiated plan price, with no deductible applied.
Two coverage limits worth knowing. By law, Medicare Part D does not cover drugs for weight loss, fertility, cosmetic purposes, or erectile dysfunction. And GLP-1 coverage depends on the diagnosis: under California’s Medi-Cal Rx program, Wegovy, Zepbound, and Saxenda were removed from the covered list for weight-loss uses effective January 2026, though Wegovy may still be approved through prior authorization for conditions such as noncirrhotic MASH or cardiovascular disease, and Zepbound for obstructive sleep apnea. Ozempic and Mounjaro remain covered for type 2 diabetes but not for weight loss.
What to Do If a Prescription Is Denied
If the pharmacy counter tells you a drug isn’t covered, you have options. Start by asking your prescriber whether a covered therapeutic alternative would work. Call Pharmacy Member Services to ask about submitting a prior authorization request. If your prescriber believes the denied medication is medically necessary, you can request a formal coverage review; approved drugs may be covered at a higher tier with greater cost-sharing.
Formal appeals follow different paths depending on your plan:
- Anthem California members use the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form, faxed to (844) 474-3347. Providers can also submit electronic prior authorization requests through CoverMyMeds or Surescripts.
- Medicare Advantage members have 60 days from the denial notice to file a standard appeal. Expedited appeals, available when a prescriber confirms that waiting the standard seven days could seriously harm your health, require a decision within 72 hours.
- Medicaid members in states such as Virginia and Indiana can request exceptions by emailing submitmyexceptionreq@anthem.com with a supporting medical reason. Medicaid prior authorization decisions are typically made within 24 hours, and the pharmacy can provide a 72-hour emergency supply while the request is processed.
Ways to Pay Less
- Fill 90-day supplies through CarelonRx home delivery instead of three separate 30-day retail fills.
- Run drugs through the Price a Medication tool on the Anthem website or Sydney Health app to find discounts on covered and noncovered medications.
- Ask whether the manufacturer offers a copay card. These are generally available to commercially insured members but not to those on Medicare or Medicaid.
- Check patient assistance programs run by pharmaceutical companies and nonprofits for uninsured or underinsured patients who meet income requirements.
- Pay with pre-tax dollars through a Health Savings Account, Flexible Spending Account, or Health Reimbursement Arrangement.
- If you’re on Medicare Part D with limited income and resources, see whether you qualify for federal Extra Help.