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
NEW Laws & Regulations effective 1.1.2017 AB 1305, 339 & 1954 SB 999 – Deductible & OOP Maximums FAQ’s
(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
(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.
Visit Our webpage on Medical Necessity
|California Senate Bill (SB) 1021 – Copayment Limits to Retail Prescription Drug Pricing|
Ex Pharma Representative Speaks Out…
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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
|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
We will use the Blue Shield Gold plan as an example.
Search all Rx
1 page pdf on how to access Rx
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
Definition of Status of Rx in Formulary List
|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|
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
|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.
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|
|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|
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
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 *
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.
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.
We do not know who they are. We are not endorsing them. We’ve heard from some of our clients, who are happy with them.
Pain Management, Opioid Crisis, Physical Therapy, etc.
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
Pain Relief Without Drugs or Surgery Harvard Medical School $20
Stress – Seeing a Psychiatrists, Shrink or Therapist
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.
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 *
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.
Is There Such a Thing as Psychological Pain? and Why It Matters National Institute of Health
Rx – Prescriptions for Pain
Lumbar Epidural Injections
Therapeutic and Diagnostics Benefits for Low Back Pain
Radiculopathy John Hopkins
Physical Therapy & Exercise
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: