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
NEW Laws & Regulations effective 1.1.2017 AB 1305, 339 & 1954 SB 999 – Deductible & OOP Maximums FAQ’s
(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;
(2) Submits its drug list to the Exchange, the State, or OPM.
(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
Related Pages in Prescriptions Drugs – Rx Section
♦ Manufacturer Discounts & Assistance