How are Drugs Rx reimbursed under the Bronze Plan (Blue Shield)?
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How does the Blue Shield Matrix (Summary of Benefits – Evidence of Coverage) Explain it?
The explantion of Rx in the Evidence of Cvoerage is quite extensive, click here to view. We’ve added yellow highlights and bookmarks.
What is the Bronze Deductible, with Blue Shield?
The Calendar Year Pharmacy Deductible is the amount a Member must pay each Calendar Year for covered Drugs before Blue Shield begins payment in accordance with the Evidence of Coverage and Health Service Agreement. The Calendar Year Pharmacy Deductible does not apply to all plans. When it does apply, this Deductible accrues to the Calendar Year Out-of Pocket Maximum. There is an individual deductible within the Family Calendar Year Pharmacy Deductible. Information specific to the Member’s plan is provided in the Summary of Benefits.
The Summary of Benefits indicates whether or not the Calendar Year Pharmacy Deductible applies to a particular Drug
Has Novolog (Insulin) been removed from the formulary ?
Check our Formulary Page on how to check that out.
Note also, that if you had Blue Shield when a Rx was on the formulary, if it’s removed, you are grandfathered to still get it as stated in the Rx FAQ section.
If a drug is removed from your formulary, members who were already receiving the drug will continue to have the medication covered for as long as the treating physician continues to prescribe the drug, provided the drug is being prescribed appropriately and is considered safe and effective for treating the member’s medical condition.
If I went to Silver plan,
I pay an extra $120/mo in premium but save $700/mo in prescriptions, rather than
100% up to OOP with bronze plan
Charge no more than up to $250 per month for one 30-day supply for Silver 70, Gold 80 and Platinum 90 plan members and no more than up to $500 per 30-day supply for Bronze 60 plan members. These costs apply to Tier 4 (specialty drugs). Drugs in lower tiers have lower costs.
It’s all a function of the Medical Loss Ratio. Insurance Companies must pay out 80% of all the premiums they take in in claims and can keep 20% for expenses, profit and overhead.
What is Medical Necessity?
A service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. (2014 ACA Sample EOC Page 166) CA WIC §14059.5
Learn More==> Our webpage on Medical Necessity
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