What is a Rx formulary?

 

 

How do I know if my Rx – Prescription is Covered?

If the drugs are generic, they should all be covered, right?

The way to check it would be to go to each insurance companies web page on this website or this page for Covered CA!!!,  (note Covered CA controls and sets standards for both Covered CA and Direct – off Exchange)   after getting a FREE quote and subsidy calculation and find the formulary.  If the formularies are not on that page, email us and we will add it.

Health Insurance Company Formulary Customer Service
Anthem Blue Cross of California Formulary (855) 634-3381
Blue Shield of California Formulary (855) 836-9705
Chinese Community Health Plan Formulary (888) 775-7888
Health Net Formulary (888) 926-5133
Kaiser Permanente Formulary (800) 464-4000
L.A. Care Health Plan Formulary (855) 270-2327
Molina Healthcare Formulary (888) 858-2150
Oscar Health Plan of California Formulary (855) OSCAR-55
Ext. 2
Sharp Health Plan Formulary (800) 359-2002
Valley Health Plan Formulary (888) 421-8444
Western Health Advantage Formulary (888) 563-2250 Covered CA 

Here’s how to check Blue Cross Formulary list.

Go to the Blue Cross Page – look for the formulary, then under Child Pages – click on Rx Prescription Benefits Follow the link to the Blue Cross webpage on formulary – drug lists. I will grant, it’s complex, mainly as it’s for members, not shoppers. I believe it’s the Select list – I got an email yesterday clarifying that on group plans…

This is one reason not to wait till the last minute to shop plans. Especially, when dealing with an unexpected extension of Open Enrollment. If one were to pick a plan at the beginning of Open Enrollment or special enrollment, they have 30 days FREE look, could cancel and still have time to pick a NEW plan!

So, just list each Rx in the search box, unfortunately Exemstane doesn’t show up. Here’s a pdf of the select RX list. One must be VERY careful with spelling!!! I googled and the correct spelling is exemestane. That is covered as tier 4.

So, go back and check out the FREE quote, click on details, compare up to three plans and see what the co pay is for tier 4 and in this case Silver 87. Thus 15% co insurance after the $50 deductible.

I will grant you that this is a LOT of work. More than I as an agent can do for a client, given the cut rate, near minimum wage commissions under Health Care Reform. That’s why we use this website so much, to give information without spending hours on the phone.

Blue Shield Formulary Search pdf

Health Net Pdf

How to request a formulary exception

We will use the Blue Shield Gold plan as an example.

Formulary Page

Pdf Formulary List

Search all Rx

1 page pdf on how to access Rx

In this case, Symbicourt is non-formulary and requires an exception based on Medical Necessity and maybe a review of the UM Utilization Management guidelines.

How does one request an exception?

Let’s take a look at the Gold Plan Evidence of Coverage.

Check out page 23 where there is an explanation of the Outpatient Prescription Drug Benefit  It says one needs prior authorization

Some drugs, most Specialty Drugs, and  prescriptions for Drugs exceeding specific quantity limits require prior authorization by Blue Shield for Medical Necessity, as described in the Prior Authorization/Exception Request Process section. The Member or his/her Physician or Health Care Provider may request prior authorization from Blue Shield.

How to get prior authorization is on page 27

The Member, his/her Physician or Health Care Provider may request prior authorization by submitting supporting information

For formulary exceptions, the prescriber’s supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee’s condition because all covered  drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be less effective, or the alternative(s) listed on the formulary or required to be used in accordance with step therapy has(have) been or is(are) likely to be less effective or have adverse effects. CMS.gov

to Blue Shield.  Once all required supporting information is  received, Blue Shield will provide prior authorization approval or denial, based upon Medical Necessity, within two business days.  Coverage requests for Non-Formulary Drugs in standard or normal circumstances will have a determination provided within two business days or 72 hours, whichever is earlier; the same requests in exigent circumstances will have a determination provided within 24 hours.

Contacting Blue Shield page 79   Customer Service toll free at 1-800-200-3242

If we are your appointed agent, no charge, we can help you do this, if you send us the supporting documents.

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

What if my Rx are not on the formulary, how can I get an exception?

Nexium-Dosage-20/22 MG-She must be on it because of her acid reflux and throat lining issue

Symbiacort-80/4.5-Must have for daily use in order to prevent breathing distress.

Oxcarbazepine-150 MG Tablet.-My daughter must be on this medication. Her Doctor said that is no replacement brand for this. Her Dr. said she MUST be on this exact prescription

Holistic alternative for erectile dysfunction to Viagra?

Definition of Status of Rx in Formulary List

Status Definition
Tier 1 Most generic drugs and low-cost, preferred brand drugs
Tier 2 Non-preferred generic drugs, preferred brand drugs, or drugs recommended by Blue Shield’s Pharmacy and Therapeutics (P&T) Committee based on drug safety, efficacy, and cost
Tier 3 Non-preferred brand drugs, drugs recommended by Blue Shield’s P&T Committee based on safety, efficacy, and cost, or drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier
Tier 4 Drugs that are required by the Food and Drug Administration (FDA) or drug manufacturer to be distributed by specialty pharmacies, drugs that require training or clinical monitoring for self administration, drugs manufactured using biotechnology, or drugs with a plan cost (net of rebates) greater than $600
Non-formulary Non-formulary

Drugs not listed that meet the Tier 4 description require a formulary exception based on medical necessity to be covered at the Tier 4 share of cost. All other drugs not listed require a formulary exception based on medical necessity for coverage at Tier 3.

Definition of Restrictions

Restriction Definition
Age Restriction Prior authorization may be required if your age does not fall within the FDA, manufacturer, or treatment guideline recommendations.
Contraceptive drugs and devices Contraceptive drugs and devices covered at no charge.

 
Contraceptive drugs and devices Contraceptive drugs and devices may be covered at no charge with prior authorization.
Gender Limit – Female Only Coverage is restricted to females.

Prior authorization may be required if the FDA, manufacturer, or treatment guidelines do not recommend the drug for a gender.

Gender Limit – Male Only Coverage is restricted to males.

Prior authorization may be required if the FDA, manufacturer, or treatment guidelines do not recommend the drug for a gender.

Limited Access Limited Access/Distribution

Only available through select pharmacies that are designated by the manufacturer.

Limits/Notes Coverage restrictions or limits for drugs.
Prior Authorization Prior authorization is required to determine coverage
Quantity Limit The prescription quantity covered is limited. Prior authorization is required for greater than the limit.
Retail & Mail Pharmacy Access Tier 4 drugs available at retail and mail order pharmacy.
Short Cycle Drug Short Cycle DrugInitial prescriptions for select Specialty Drugs can be dispensed for a 15 day trial supply. The applicable Copayment or Coinsurance will be pro-rated.
Specialty Pharmacy Must be obtained through a network specialty pharmacy.
Step Therapy Coverage is determined based on use of other first-line therapies/drugs. Copied from BS Website

4 comments on “Is my prescription on the formulary – approved list?

    • Here’s the formulary for the AARP 2019 Medicare Rx Saver Plus, the exact plan that you have.

      Page 56 shows Livalo as Tier 3 Preferred Brand Name Page 5 with QL – Quantity limited to 1/day Page 89

      Here’s what the summary of benefits shows you should be paying

      Tier 3: Preferred Brand Drugs

      Preferred Pharmacy Network
      Cost Sharing (30 days)
      $25 copay

      Standard Network Pharmacy
      Cost Sharing (30 days)
      $30 copay

      Preferred Mail Order Pharmacy
      (90 days)
      $75 copay

      Standard Mail Order Pharmacy
      (90 days)
      $90 copay

      I would suggest that you show this to your pharmacy and have them call AARP. If you are taking more than 1 tablet per day, we can check on this further.

      Toll-free 1-866-460-8854, TTY 711 8 a.m. – 8 p.m. local time, 7 days a week

      What if I’m taking a drug that isn’t on my plan’s drug list when my drug plan coverage begins?

      Generally, your drug plan will give you a one-time, temporary supply of your current drug during your first 90 days in a plan. Plans must give you this temporary supply so that you and your prescriber have time to find another drug on the plan’s formulary (drug list) that will work as well as what you’re taking now, or you or your prescriber can contact the plan to ask for an exception. There may be different rules for people who move into or already live in an institution (like a nursing home or long-term care hospital). Medicare Rx Manual # 11109 Page 30

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