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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Ex Pharma Representative Speaks Out…
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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 if a drug is covered under your 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 formulary. 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
How to request a formulary exception
We will use the Blue Shield Gold plan as an example.
Formulary Page
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 |
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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 |
What is a Rx formulary?
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
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
Insure Me Kevin.com Silver vs Bronze
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. AB 339 Gordon * CAPG.org * Keenan.com *
That’s one reason that under Guaranteed Issue ACA – Obamacare you can only enroll at Open Enrollment or if you have a special reason – change of circumstance during the year.
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.
Holistic alternative for erectile dysfunction to Viagra?
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) * Our webpage on Medical Necessity * CA WIC §14059.5
Please note, we were asked this question in 2018. Things change every year. Thus, we took down some of the graphics. Use the links to find the most current information!
Click here to get a quote/proposal for your personal situation, including subsidies.
How does the Blue Shield Matrix (Summary of Benefits – Evidence of Coverage) Explain it?
Covered CA Explanation from Metal Level Comparison Chart
The explanation of Rx in the Evidence of Cvoerage is quite extensive, click here to view. We’ve added yellow highlights and bookmarks.
Pain Management, Opioid Crisis, Physical Therapy, etc.
Dr. Oz: How to Treat Chronic Pain Without Drugs
Breakthrough in the Relief of Chronic Pain Without Drugs!
We’re Experiencing a Crisis in Pain Management. Can We Treat It Without Drugs?
How You Can Manage Your Pain Without Medications With OMT, Acupuncture and an Anti-Inflammatory Diet
Understanding your alternatives
How Can You Relieve Chronic Pain — Without Drugs?
Cognitive behavioral therapy helps guide thoughts, actions
Drug-Free Remedies for Chronic Pain
Escape from pain — without drugs
8 Proven Ways to Manage Chronic Pain Without Medication
How to Treat Your Pain Without Drugs
8 Surprising (And Natural) Ways To Beat Pain
When it comes to your chronic aches and pains, the new gold standards aren’t what you think
Management of Pain without Medications
Is it possible to manage pain well without opioids?
Pain Relief Without Drugs or Surgery Harvard Medical School $20
11 Tips for Living With Chronic Pain
Guide to Posture in the Workplace
Repetitive Motion Injury Prevention
Poster: Keep Motion Injuries at Bay
Stress – Seeing a Psychiatrists, Shrink or Therapist
The Ten Biggest Mistakes Psychiatrists Make
6. Don’t refer to therapy.
Psychopharmacology without therapy is treating an infection with Tylenol.
Medications do not cure a psychiatric disease; we’re not even sure what the disease actually is. What they can do is reduce symptoms, give you strength—so that you can learn new behaviors. That’s the point of medications. Treating depression with an antidepressant is not the solution; it’s the preliminary step in allowing you to figure out how to handle depression later on. The adaptation, the adjustment, the physical altering of brain functioning is done by new learning, often this is therapy (though it doesn’t have to be.) I’m not saying therapy is that great, or necessary, either. I’m simply saying that trying to improve a person’s long term status using medications alone without some sort of education and training is a waste of time. It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment.
8. Polypharmacy
Polypharmacy isn’t just common– it’s the codified standard. When two psychiatrists discuss a patient, inevitably one of them will say these four words: “You should consider adding…” The Last Psychiatrist.com *
10 Ways Depression and Anxiety Can Cause Physical Pain
Can Mental Illness Cause Physical Pain?
There are indeed mental illnesses that can cause people to experience pain, numbness and a variety of other “physical” symptoms. They are known as Somatoform Disorders.
Somatic Symptom and Related Disorders Web MD
New Test Distinguishes Physical From Emotional Pain in Brain for First Time
13 Ways That Emotional Pain Is Worse Than Physical Pain
Is There Such a Thing as Psychological Pain? and Why It Matters National Institute of Health
The Link Between Depression and Physical Symptoms
How Emotional Pain Affects Your Body
Emotional and Physical Pain Activate Similar Brain Regions
Where does emotion hurt in the body?
5 Ways Emotional Pain Is Worse Than Physical Pain
Why emotional pain causes longer lasting damage to our lives
8 Physical Symptoms That Prove Depression Is Not Just ‘In Your Head’
We don’t often pair depression with physical pain but research shows this mental illness can really hurt.
Rx – Prescriptions for Pain
Lumbar Epidural Injections
Therapeutic and Diagnostics Benefits for Low Back Pain
Radiculopathy John Hopkins
Visit our webpage on the clinical guidelines for Rx Medication
Rx Drug Abuse
Prescription drug abuse Mayo Clinic
Medicare Provider Finder https://www.medicare.gov/physiciancompare/
If you have Medi Cal, you probably have a Medi Cal HMO – follow these links to find their provider finder:
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/health-net-solutions/
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/la-care/
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/la-care/anthem-blue-cross/
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/la-care/care-1st-blue-shield/
https://medi-cal.healthreformquotes.com/hmo-managed-care-providers/la-care/kaiser-medi-cal/
Related Pages in Prescriptions Drugs – Rx Section
Our website LIS Low Income Subsidy
♦ Medicare Part D Rx this website
♦ Manufacturer Discounts & Assistance
7 comments on “Is my prescription on the formulary – approved list?”
Is Latuda covered by any Covered CA company?
What is the co pay?
Covered CA nor the Insurance Company’s pay enough for brokers to do extensive research…
Here’s Blue Shield’s Formulary
Search
Well, even if agents were getting fair compensation getting a formulary exception is beyond our pay grade. Have your doctor review the formulary exceptions above and get the Insurance Company that you want to approve the Rx.
See also our webpage on continuity of care. While you’re entitled to the same MD, I don’t know about the same Rx and treatment.
Check https://www.latuda.com/bpd/latuda-savings-and-support.html
LATUDA Copay Savings Program Terms and Conditions
By using this card, you acknowledge that you currently meet the following eligibility requirements:
You must be 18 years of age or older to accept this offer. This offer is valid only for eligible patients and legal guardians of eligible patients. Patients must have a valid prescription for LATUDA within LATUDA’s approved indications
Offer not valid if prescription is paid in part of full by any state or federally funded health care program, including but not limited to Medicare, Medicaid, VA, DOD or TRICARE, or where prohibited by law
This card is valid for up to $400 off each prescription fill for up to a 30-day supply. The card is further limited to twelve (12) qualifying prescription fills per calendar year
Offer is limited to one per person and may not be used with any other offer
This program is not health insurance. The amount of the benefit cannot exceed the patient’s out-of-pocket expenses. Acceptance of this offer must be consistent with the terms of any drug benefit provided by a health insurer, health plan, or other third-party payer. If requested or required by any such payer, the patient must report the use of this card. The patient must deduct the value of the savings received under this program from any reimbursement request submitted to the patient’s insurance plan, either directly or on the patient’s behalf.
For California and Massachusetts residents, benefits pursuant to this card will terminate automatically upon the introduction of a therapeutically equivalent product
Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed or restricted
Sunovion reserves the right to rescind, revoke, or amend this offer at any time without notice. This offer is not transferable and may not be sold, purchased or traded, or offered for sale, purchase or trade
*Must meet eligibility requirements. For commercially insured patients, this Copay Savings Card covers out-of-pocket expenses greater than $15 per prescription, with up to a maximum benefit of $400 for a 30-day supply. The card is further limited to twelve (12) qualifying prescription fills.
https://www.latuda.com/bpd/latuda-savings-and-support.html
I have a Medicare Rx Plans with AARP UHC United Health Care. https://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/ Last year it was with Humana.
Today I went to pick up Livalo tab (cholesterol med.) they want $320 co-pay.
Humana charged only $120.
What do I do?
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
CVS formulary based on health of individual
http://www.pipcpatients.org/resources/cvs-letter?utm_source=Facebook-Promoted&utm_medium=Social&utm_campaign=PIPC&utm_term=02020501050300&utm_content=CVSLetter
21 comments on “Bronze Plan – How are Drugs Reimbursed?”
do “out-of-pocket” limits include the deductibles? Or is it only accrued after deductible is met?
Here’s our page where we explore OOP Maximum Out of Pocket and what it means.
Yes, OOP includes the deductible. Here’s an excerpt of page 122 from the Blue Shield Evidence of Coverage:
If I don’t like the Rx plan that I have, do I have to wait for Open Enrollment?
How about Special Enrollment?
If my employer (not enough employees for a group plan) was contributing to my premiums and he changes the contribution amount would that qualify?
Yes, you must wait for Open or Special Enrollment.
For a simple English explanation of the rules about change in employer contribution… Here’s Blue Shield’s. See checklist # 4 & 5.
The details and actual code are on our Special Enrollment Page.
This is rather complex. I’m not an attorney or CPA. If you’re employer stops paying premium, then you may lose tax benefits. I’ve enrolled people under special enrollment who have lost coverage, but not whose employer went say from 100% of premium to say 75%. I’d have to search to see if there is guidance on that. The CFR cited above is 12 pages…
Did you have time to research the “guidance” in the Code of Federal Regulations?
Sorry, no. I’m getting ready to leave for vacation. There is really no one at Covered CA or Blue Shield that I can ask an intelligent question of. Blue Shield’s auto responder says it can take 45 days to get an answer.
Covered CA would rather I fill out Medi-Cal applications for NO COMPENSATION, rather than do any real research. Covered CA has threatened to terminate my contract for cause, as I asked them to finish up a Medi-Cal enrollment, where there website would not work.
If I’m lucky, I make 1.4% commission on a Blue Shield policy. Doesn’t leave a lot of time for research and product knowledge.
President Obama said that the Metal Levels would make shopping easier. ACA did make everything guaranteed issue. In the past, with underwriting, someone with diabeties would have difficulty getting an individual plan. Covered CA is happy to write the people that I had on HIPAA policies – when their COBRA expired, thus cutting into the 1.4% commission, while sending me Medi-Cal leads, with no commission. They spent $100M last year on advertising and nothing on lunches for agents.
Did you want to know how I really feel?
I reviewed the guidance on changes in employer contributions and don’t find anything of value to making a change. All I can suggest is to submit the documents and see.
Covered CA takes your word for it under penalty of perjury and does some spot checking.
(e) The Exchange shall accept the qualified individual’s or the enrollee’s attestation provided in accordance with subdivision (d) of this section, subject to the following statistically valid random sampling verification process:
My employer now pays 100% of my health insurance.
I understand this will be ending soon (probably June 30) and my employer is drafting a letter to send to notify employees. The letter will probably go out before end of May.
From the info here, I see this is a qualifying event, and means I have 60 days before and 60 days after to make a change to my health plan. I’m thinking change before June 15 for new coverage starting July 1.
Yes, I agree with your analysis of the things we posted on this page and our special enrollment page. https://individuals.healthreformquotes.com/open-enrollment-for-individuals-families/ccr-code-regulations-ca-%c2%a76504-special-enrollment-periods/
Here’s a graphic from Blue Shield’s simplified summary.
Please note also, if there are non owner or spousal employees, you would then qualify for a Group Plan https://employers.healthreformquotes.com/ab-1083/employer-definition/
Get Quotes for Groups here https://www.quotit.net/Quotit/Apps/EproV2/ZipEntry?license_no=0596610&brokerIdHash=159821451
I was not given full and correct information about these plans. The prescription costs, co pays, deductibles, OOP, etc. were never available–blue shield does not provide any way to check on costs before you enroll, so can’t compare costs and benefits.
Clearly, the prescription costs Humalog – Novolog are more than my Bronze premium each month so providing premium prices without also allowing prescription cost checking is misleading.
Might this be a “material violation” so that I can get a special enrollment period?
See the 1st four screen shots above, those were available on this website and are linked to from Covered CA and Blue Shields websites. The quote engine shows Bronze as having no coverage until the OOP is met. I do grant that Blue Shield’s summary of benefits is confusing as it says you pay 100% up to $500. One has to know about AB 339 to understand the limits that were put in to protect those with very high Rx Costs.
This page shows how to check an Insurance Companies formulary to see if your Rx is on it. It also shows how to get an exception made for the formulary.
CA Insurance Code 10276 guarantees the right to view the EOC before purchase and to reject the policy with a 30 day free look.
This page is prior research on diabetic medications.
You do have a point, Medicare.Gov will shop and show the benefits for all part D Rx plans.
Material Violations are listed in the Blue Shield summary # 14. I’ve never been able to prove one.
President Trump Insurance is very complicated
https://embed.theguardian.com/embed/video/us-news/video/2017/feb/27/trump-healthcare-complicated-budget-video
Here’s the Blue Shield Formulary Search Page
Search Results for Humalog – We really need to know the exact description.
the diabetes council.com/humalog-vs-novolog-whats-the-difference/
Non-formulary HORIZANT ER 600 MG TABLET,EXTENDED RELEASE
Tier 2 HUMALOG JUNIOR KWIKPEN (U-100) 100 UNIT/ML SUBCUTANEOUS HALF-UNIT PEN
Tier 2 HUMALOG KWIKPEN (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS
Tier 2 HUMALOG KWIKPEN U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS
Tier 2 HUMALOG MIX 50-50 (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION
Tier 2 HUMALOG MIX 50-50 KWIKPEN U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN
Tier 2 HUMALOG MIX 75-25 (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION
Tier 2 HUMALOG MIX 75-25 KWIKPEN U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN
Tier 2 HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS CARTRIDGE
Tier 2 HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION
The tier level doesn’t show when I did a cut & paste, but Novolog is Non Formulary
Novolog Flexpen U-100 Insulin aspart 100 unit/mL subcutaneous
Novolog Mix 70-30 FlexPen U-100 Insulin 100 unit/mL subcutaneous pen
Novolog Mix 70-30 U-100 Insulin 100 unit/mL subcutaneous solution
Novolog PenFill U-100 Insulin aspart 100 unit/mL subcutaneous cartridg
Novolog U-100 Insulin aspart 100 unit/mL subcutaneous solution
See page iii for how to get exceptions to the formulary list…
If you scroll to the 2nd screen shot from the top – Tier 2 Rx Preferred Brand Name Co-Pays are shown. In Bronze, you must meet the OOP Max, Silver the $2,500 deductible, then $55 Co Pay, Gold $55 Co Pay, Platinum $15. Platinum is twice the premium of Bronze. It’s all based on 80% Medical Loss Ratio.
This page compares costs of humalog at various pharmacies. wellrx.com/prescriptions/humalog
To be clear, my complaint about lack of info from Blue Shield is that they don’t disclose what a drug COSTS (before insurance pays).
To be clear, my complaint about lack of info from Blue Shield is that they don’t disclose what a drug COSTS (before insurance pays).
They DO say what PERCENT I will pay, but 100% of what?
I never thought my $15 script would be now $260, and my $25 is now $500. I don’t see any way to check those costs with Blue Shield before enrolling (I can check current coverage only), Although I can look at drug prices for uninsured customers at pharmacies.
For reference when I had to refill my $15 Lantus insulin prescription out of sequence in 2009 or so… after I broke a vial [i.e. no insurance coverage because they only pay every 30 days], before ACA, I paid $125 so thought that was the cost not $260.
However, i thought it would work like out-of-network doctors–typically even if Blue Shield pays $0 for a service, they allow members to pay the reduced contracted amounts for the service, often a huge discount. I assumed insurance companies had negotiated similar arrangements with pharmacies and drug companies, especially since they wield huge buying power with formularies.
Formulary isn’t the issue–Novolog (not on formulary) is around $550. My doc offers to switch me to Humalog (on formulary) at $500/mo. Same cost to me. Plus I’m not sure we get to see the coming year’s formulary or changes during open enrollment–it’s bait and switch?
It also looks like drug companies are pricing to hit the $500 limit– I see several drugs there.
The formulary is published, but I saw discussion that insurance companies are playing games with formularies–seems one of the variables they can control. For example it seems odd that Novolog is on 1 of the 2 (maybe more?) formularies Blue Shield has. You mentioned it has to do with cost and group size, but is that what ACA intends or specifies–that individuals can’t get some drugs covered (at any premium level) but groups can?
I haven’t read and reviewed this yet but here’s a study by CMS I negotiated rates and whether it’s a participating or non-participating pharmacy
This would apply to part D Medicare I’m not sure how much it applies to Obamacare
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/PharmacyNetwork.pdf
The link above https://www.wellrx.com/prescriptions/humalog took me to a site that seems to offer discount prices (the prices listed are much lower than I’ve seen before, several hundred $$$ less), but appears to require that I print a coupon and take it to pharmacy.
But I don’t need to pay or join or sign up–seem too good to be true?
Are these legit?
Is it a 1-time thing or can I use the coupon/discount every month when I refill the prescription?
is there a catch?
I got a card like this in the mail but thought it must be a scam and threw it away.
See also our page on Manufacturers Coupons.
Here’s their FAQ section
FAQs
How do I use this discount?
Print this page and show it at the pharmacy counter when you pay for your medication.
Can I use this discount with Medicare or my insurance?
No. This discount cannot be used together with insurance. However, sometimes the discounted price is less than your co-pay, in which case you may choose to use the discount instead of your insurance. If you have Medicare and are enrolled in a Medicare Part D plan, use this discount to save on any prescriptions that are excluded from coverage.
What if the pharmacy won’t accept the discount?
The price displayed is contracted with the pharmacy. Please contact (800) 407-8156 and our customer care specialists will help to resolve the issue.
Can I re-use this discount?
Yes you can! However, we recommend getting a savings card as we think they are better looking. For an even better option, why not download our app so your card is always with you.
Here is their “about us” page
I can’t really answer your question about discount programs being legit…. If you find any research, please post below.
Well Rx Video – save $$$
https://www.youtube.com/embed/cW3UgWPNFro
You might check with your CPA about Section 105 Medical Expense Reimbursement, where your employer pays what isn’t covered by Insurance.
I would like to change from Bronze to Silver, mainly for prescription benefits, but want to do some more research and welcome any insight or thoughts you have.
Do you think it will cause any issues if I switch to a higher metal tier? (which I believe is less expensive all things considered)
Please review this entire page and the quotes that we’ve sent though our quote engine. Anyone can get a quote and analysis by clicking here http://www.quotit.net/eproIFP/webPages/infoEntry/InfoEntryZip.asp?license_no=0596610
As long as you qualify for special enrollment, it’s all guaranteed issue. It won’t matter if you go up or down in coverage.
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.