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
(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.
Procedures shown in “Blue Cross” specimen policy. ♦ Blue Cross 2014 Drug List
Visit Our webpage on Medical Necessity
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