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  ♦  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


(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


Procedures shown in “Blue Cross” specimen policy.  ♦  Blue Cross 2014 Drug List

Visit Our webpage on Medical Necessity

Holistic alternative for erectile dysfunction to Viagra?

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.

Prescription Drugs  – UM Guidelines
Clinical UM – Utilization Management Bulletins
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®) and Direct Thrombin Inhibitors in the Outpatient Setting
CG-DRUG-05 Recombinant Erythropoietin Products
CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy
CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease
CG-DRUG-09 Immune Globulin (Ig) Therapy
CG-DRUG-11 Infertility Drugs
CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy
CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults
CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs
CG-DRUG-16 White Blood Cell Growth Factors
CG-DRUG-18 Nesiritide (Natrecor®)
CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women
CG-DRUG-20 Enfuvirtide (Fuzeon®)
CG-DRUG-21 Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence
CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
CG-DRUG-27 Clostridial Collagenase Histolyticum Injection
CG-DRUG-28 Alglucosidase alfa (Lumizyme®, Myozyme®)
CG-DRUG-29 Hyaluronan Injections in the Knee
CG-DRUG-30 Oprelvekin (Neumega®)
CG-DRUG-31 Oncology Drug Treatment Regimens for Adults **NOTE: At this time, this guideline is not implemented for medical benefit determinations
CG-DRUG-33 Palonosetron (Aloxi®)
CG-DRUG-34 Docetaxel (Taxotere®)
CG-DRUG-38 Pemetrexed Disodium (Alimta®)
CG-DRUG-40 Bortezomib (Velcade®)
CG-DRUG-41 Zoledronic acid
CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase)
CG-DRUG-43 Natalizumab (Tysabri®)
CG-DRUG-44 Pegloticase (Krystexxa®)
CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
CG-DRUG-46 Fosaprepitant (Emend®)
CG-DRUG-47 Level of Care: Specialty Pharmaceuticals

Ex Pharma Representative Speaks Out…


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10 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 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.

  3. 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


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