How are Drugs Rx reimbursed under the Bronze Plan (Blue Shield)? 

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  Silver vs Bronze

Pharmacy Cap $500 then 30% ?

Covered CA on Rx Benefits

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  *  *  *

Covered CA Claim Scenarios

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.


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

 If any of the screenshots are blurry or too small for you to read, just click on them to enlarge or to view on the source document

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.


Evidence of Coverage - Markup, Bookmarks, Etc.
Evidence of Coverage – Markup, Bookmarks, Etc.

21 comments on “Bronze Plan – How are Drugs Reimbursed?

  1. 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:

      Out-of-Pocket Maximum [means]

      the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year as indicated in the Summary of Benefits.

      Charges for services that are not covered, charges in excess of the Allowable Amount or contracted rate do not accrue to the Calendar Year Out-of-Pocket

  2. 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.

      10 CCR CA Code of Regulations
      §6504 Special Enrollment Periods

      (a) A qualified individual fn 1 may enroll in a QHP, or an enrollee fn2 may change from one QHP to another, during special enrollment periods only if one of the following triggering events occurs:

      (8) A qualified individual, or his or her dependent, who is enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC because such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.

      (2) Termination of employer contributions toward the employee’s or dependent’s coverage that is not COBRA continuation coverage, including contributions by any current or former employer that was contributing to coverage for the employee or dependent;

      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…

        • 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 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.

        (5) A qualified individual’s, or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct, as determined by the Exchange, includes the failure to comply with applicable standards under this title, or other applicable Federal or State laws.
        (6) An enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
        (14) The qualified individual or enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that a material error related to plan benefits, service area, or premium influenced the qualified individual’s or enrollee’s decision to purchase a QHP through the Exchange.

      • Here’s the Blue Shield Formulary Search Page

        Search Results for Humalog – We really need to know the exact description.
        the diabetes


        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.

        • 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?

        • The link above 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


            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.

    • 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)

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