Prescription Drugs – Rx

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.  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

and

(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

Visit Our webpage on Medical Necessity

Ex Pharma Representative Speaks Out...

 

California Senate Bill (SB) 1021 – Copayment Limits to Retail Prescription Drug Pricing

 

SB 1021 extends the sunset date for AB 339 (Healthcare Coverage for Outpatient Prescription Drugs), which included provisions related to pharmacy cost-share maximums and formulary standards.

SB 1021 also includes a provision to limit member cost-share to the contracted retail price if it is lower than the member’s copayment or coinsurance. This means when a member purchases an outpatient prescription drug from a participating pharmacy and the pharmacy’s contracted rate for the prescription drug is less than the member’s copayment or coinsurance, the member pays only the contracted retail price. This cost-share amount is also applied to the member’s deductible and out-of-pocket maximum (OOPM), if applicable.

SB 1021 extends this specific provision until January 1, 2023.

Click here for more information about California Senate Bill (SB) 1021.

8 comments on “Prescriptions Drugs – Rx

  1. My primary doctor referred me to a pain doctor that I have been seeing for three years never have missed an appointment.

    My pain doctor got mad at me after three years because he wanted me to stop a medication that my psychiatrist was giving me. It was only a 1/2 of pill .

    My psychiatrist wrote my pain doctor and told him there was no need to stop my medication as I only take it as needed. I’ve been doing fine for years on the medication.

    No other doctor ever have complained about the medication and the pain doctor didn’t start complaining until after three years. Now the pain doctor cut my pain medication down to nothing.

    I’m a chronic pain patient what do I do ?

  2. 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

    Thanks,

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