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
(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
| California Senate Bill (SB) 1021 – Copayment Limits to Retail Prescription Drug Pricing | |
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CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use |
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CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis |
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CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®) and Direct Thrombin Inhibitors in the Outpatient Setting |
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CG-DRUG-05 Recombinant Erythropoietin Products |
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CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy |
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CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease |
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CG-DRUG-09 Immune Globulin (Ig) Therapy |
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CG-DRUG-11 Infertility Drugs |
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CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy |
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CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults |
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CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs |
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CG-DRUG-16 White Blood Cell Growth Factors |
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CG-DRUG-18 Nesiritide (Natrecor®) |
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CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women |
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CG-DRUG-20 Enfuvirtide (Fuzeon®) |
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CG-DRUG-21 Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence |
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CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel) |
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CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting |
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CG-DRUG-27 Clostridial Collagenase Histolyticum Injection |
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CG-DRUG-28 Alglucosidase alfa (Lumizyme®, Myozyme®) |
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CG-DRUG-29 Hyaluronan Injections in the Knee |
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CG-DRUG-30 Oprelvekin (Neumega®) |
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CG-DRUG-31 Oncology Drug Treatment Regimens for Adults **NOTE: At this time, this guideline is not implemented for medical benefit determinations |
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CG-DRUG-33 Palonosetron (Aloxi®) |
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CG-DRUG-34 Docetaxel (Taxotere®) |
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CG-DRUG-38 Pemetrexed Disodium (Alimta®) |
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CG-DRUG-40 Bortezomib (Velcade®) |
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CG-DRUG-41 Zoledronic acid |
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CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase) |
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CG-DRUG-43 Natalizumab (Tysabri®) |
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CG-DRUG-44 Pegloticase (Krystexxa®) |
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CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot) |
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CG-DRUG-46 Fosaprepitant (Emend®) |
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CG-DRUG-47 Level of Care: Specialty Pharmaceuticals |
Related Pages in Prescriptions Drugs – Rx Section
Our website LIS Low Income Subsidy
♦ Medicare Part D Rx this website
♦ Manufacturer Discounts & Assistance
Ex Pharma Representative Speaks Out…
Instant Term Life Quotes
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Tools to help you figure out how much you should get
Video on how much coverage for death protection you need
https://californiahealthline.org/news/many-health-plans-must-now-cover-full-cost-of-expensive-hiv-prevention-drugs/
Health Net – How to take your Rx the right way
https://steveshorr.com/steveshorr/ab_1672_small_group_guaranteed_issue/Health_Net/2020/Taking-Your-Medication.pdf
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 ?
We are NOT doctors and can’t really give you any advice. You did not tell us what Rx you’re taking nor the cause of the pain.
Here’s some suggestions and background information on the opioid crisis:
Our webpage on Prescription Rx Utilization Management Guidelines
Our research has turned up so much information that we are creating a new page on pain management, opioid crisis, physical therapy here.
Co pays. Mfg coupons. Meeting deductible
https://www.latimes.com/business/lazarus/la-fi-lazarus-healthcare-copay-accumulators-20180427-story.html
I have about 8 generic drugs I fill every month. Which is the least expensive plan for drug co-pays?
How do you mean “least expensive?”
The plan with the highest benefits would be Platinum. Platinum would also have the highest premium. It’s all a function of the Medical Loss Ratio, the Insurance Companies, pay out 80% in claims and keep 20% for expenses.
See the Metal Level Chart here. If you qualify for CSR – Enhanced Silver, than 87 or 94 might be better.
When you use our complementary quote engine, you can see all this side by side. See screen shot below.
You might also want to double check each companies formulary, what Rx they pay for at what level. See also the question below from M. Shah, where we go into more detail on checking formulary lists.
Here’s how the quote engine shows it. When you use the quote engine, your results will be more readable, rather than our “screen shot.”
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,
Thanks for your question. It’s a bit more complicated than you might think, so we will answer it on this page.