Ex Pharma Representative Speaks Out…

Prescription Drugs – Rx

are an essential mandatory benefit  of Health Care Reform.    Watch this page for more information.  Be careful of the narrow lists – formularies under Health Care Reform.

Some insurers are alleged to be using Rx costs and formularies to discourage people with Pre-Exisiting Conditions from enrolling, despite Health Care Reforms promise of Guaranteed Issue and no Pre-X.  Learn More⇒ CA Health Line 1.29.2015

Covered CA caps Rx co-pays for specialty Rx at $250 for Silver Metal Levels & above, $500 for Bronze Plans.  Learn More⇒ AB 339  ♦   Insure Me Kevin.com  ♦  Los Angeles Times 5.22.2015

NEW Laws & Regulations effective 1.1.2017  AB 1305, 339 & 1954  SB 999 – Deductible & OOP Maximums FAQ’s

CFR §156.122   Prescription drug benefits.

(a) A health plan does not provide essential health benefits unless it:

(1) Subject to the exception in paragraph (b) of this section, covers at least the greater of:

(i) One drug in every United States Pharmacopeia (USP) category and class; or

(ii) The same number of prescription drugs in each category and class as the EHB-benchmark plan;

California Benchmark Plans ♦ Kaiser HMO 30 (1 Page),  ♦  2 Page,  ♦ all plans brochure (30 Pages),  ♦  Evidence of Coverage 64 pages


(2) Submits its drug list to the Exchange, the State, or OPM.

blueshieldca.com/Standard_Formulary.pdf  ♦  blueshieldca.com//faqs/

(b) A health plan does not fail to provide EHB prescription drug benefits solely because it does not offer drugs approved by the Food and Drug Administration as a service described in §156.280(d) of this subchapter.

(c) A health plan providing essential health benefits must have procedures in place that allow an enrollee to request and gain access to clinically appropriate drugs [medically necessary?] not covered by the health plan.

Please have your MD contact BS to convince them the brand name is the only thing that will work.  800. 535.9481 Fax 888.697.8122 ♦ blueshieldca.com/drug-prior-authorization  ♦  blueshieldca.com/exceptions-appeals

Procedures shown in “Blue Cross” specimen policy.  ♦  Blue Cross 2014 Drug List

Medical Necessity

Related Pages in  Prescriptions Drugs – Rx  Section

Our website  LIS Low Income Subsidy

♦  Medicare Part D Rx this website

Manufacturer Discounts & Assistance

6 comments on “Prescriptions Drugs – Rx

  1. I could not find how to check medications I am on, are covered under the Plan or not. My generic medications:

    Exemstane 25mg,
    Sertaline 50 mg
    Amlodipine 5 mg
    Lansoprazole 30 mg


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