Prescription Drugs – Rx

How do I know if my Rx – Prescription is in the formulary – #Covered?


1st What is a Formulary – definition?

A list of preferred Generic and Brand Drugs maintained by the Insurance Companies Pharmacy & Therapeutics Committee. It is designed to assist Physicians in prescribing Drugs that are Medical Necessary and cost-effective. The Formulary is updated periodically. Benefits are available for Formulary Drugs. Non-Formulary Drugs are covered when the Insurance Company  or an external reviewer (see our appeals & grievances webpage) approves an exception request. EOC page 110 *

If you are eligible for Medicare Part D Rx, there is a shopping tool that searches all the plans!

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

Quotit - sample quote

Click on plan details to get more information.

Rx Tier Detail

I will grant you that this is a LOT of work.


We can’t stress this enough, the BEST way to find out what YOUR plan covers is in your EOC Evidence of Coverage.

Rx benefits from EOC

2nd best is our website, 3rd is the one we link to, as it’s a popular plan in CA.

How to request a formulary #exception

  • Blue Shield for example shows their procedure for Prior Authorization, exceptions & step therapy on page 71 of the EOC
  • Oscar Pharmacy Clinical Guidelines  (Medical Necessity) We are showing Oscar as IMHO their guidelines are easier to read.
  • 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 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
    • 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.
  • Once all required supporting information is  received, xxx 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 your insurance company  page 79   Check their EOC Evidence of Coverage.  Customer Service toll free at 1-800xxx
    • If we are your appointed agent, no charge, we can help you do this, if you send us the supporting documents from your doctor.
  • 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


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


Here’s the links to check All the plans in the Individual Market.

Covered CA - Formulary Search

How to check the  Formulary list.

Let’s not reinvent the wheel, here’s where I did extensive research in April 2022 on how to search Kaiser’s Employer Small Group formulary with VIDEO’s and everything.

Formulary research is one BIG reason not to wait till the last minute to shop plans.  If one were to pick a plan at the beginning of Open Enrollment or special enrollment, they have 30 days FREE look, where one could cancel and still have time to pick a NEW plan!

So, just list each Rx in the search box.   How to use Ctrl F if it’s pdf  *  VIDEO

How to find what Medications in the Formulary for  #psoriasis

Kaiser Drug Formulary Use the CA Commercial Formulary

I'm checking to verify if your group has a 2 or 3 tier formulary. Also, we will check the Co-Pays and Tiers for your group...
See plan highlights for general information and your co pays

Your group has the option of The Silver 70 HMO 1650/55 and The Silver 70 HDHP 2500/20% HMO

What do the abbreviations mean?
quantity limts

Use Ctrl F to search for the Rx you want to check out

ctrl f

Tier level and quantity level - See highlights above for co pays or just wait till I get the EOC


Just as an FYI - See our webpage Q & A for Medicare Part D Rx on Enbrel & Humira

3 tier formulary

Taltz list price is $6k/month per their website

Kaiser Small Group Evidence of Coverages

Please review the Formulary Exception Process on page 54
EOC #2 - Kaiser Permanente for Small Business Combined Evidence of Coverage and Disclosure Form for {SAMPLE}Kaiser Permanente Silver 70 HMO 1650/55 + Child Dental Alt INFGroup ID: {PID} EOC Number: 2

See also the EOC on grievances - our webpage on grievances and appeals.

I haven't seen where Metal Level has anything to do with the formulary, in fact it's probably prohibited, as only the co pays and deductibles are supposed to be different. Here's where we did extensive research on Flomax and shouldn't it be covered on a Platinum Plan?


FYI - Medicare Part D has a shopping tool, that tells you at ONE time, all the plans and if they cover what prescriptions - I'm not aware of a feature like that for Small Group or Individual.

Specimen Individual Policy #EOC with Definitions

Employer Group Sample Policy

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

VIDEO Steve Explains how to read EOC

Videos by Steve Shorr

“Is my prescription on the formulary – approved list?”

Prescription Drug 2022 #RxGuide
PDF # 11109

part d video explanation



Coverage Gap - Donut Hole $2,000 Cap


Prescription Drugs – Rx  are an essential mandatory benefit  of Health Care Reform

Prescription drug benefits.
CFR Code of Federal Regulations §156.122

(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.

Be sure to take your Rx the way your doctor, pharmacist and Rx manufacturer suggest.

Visit Our webpage on Medical Necessity

Holistic alternative for erectile dysfunction to Viagra?

Guaranteed Issue under ACA/Obama Care

All our plans are Guaranteed Issue with No Pre X Clause
Quote & Subsidy #Calculation
There is No charge for our complementary services

Guaranteed Issue - No Pre X Clause - Quote & Subsidy Calculation - No charge for our complementary services - If not in CA click here for Nationwide Quotes

Watch our 10 minute VIDEO
that explains everything about getting a quote

Full detailed explanation of how to use our quote engine video

How are Drugs Rx #reimbursed under the Bronze Plan (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


Evidence of Coverage - Markup, Bookmarks, Etc.




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.

Mind over Matter
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 *



Rx – Prescriptions for Pain


Physical Therapy & Exercise


Exercises for the Fifth Lumbar 

Rx Drug Abuse


  • The Opioid Crisis in America and How Employers Can Help

Medicare Provider Finder

Medi Cal Provider Finder


Below is the Covered CA Standard #Metal Level Chart

See the bottom part for Co Pays amongst the Metal Levels…

2024 Metal Levels Co Pays  Deductibles

What is the co pay?
Is CVS a participating pharmacy?


You can find your plan summary using this tool
Your PPO plan uses the select drug list.
Here is where Blue Cross shows all their various Rx lists information/
Small Group Select Drug List (Searchable) | (PDF)
WOW, it’s not on the formulary!!!

If my medicine isn’t on the drug list, what are my options?


Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.
o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.
o You can search for generic drugs at OTC drugs aren’t shown on the list.
o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it.
CoverMyMeds is Anthem’s Preferred Method for Receiving ePA Requests
If your request is approved, the amount you pay for the drug will depend on your plan’s benefit

Insurance Companies are mandated to pay 85% of the premiums in claims. I guess Blue Cross figures if they pay too much for flomax, it will be way over that.  80% Medical Loss Ratio (MLR) – Actuarial Value

APPROVAL CRITERIA for Rx that are not on the Formulary 

I. The individual must meet one of the following criteria to receive a non-formulary medication for formulary co-pay;

A. Individual has previously tried and failed 2 (two) formulary products (when available):
One of which has to be in the same specific drug class; the other product can be in a
different drug class however it must have the same indication as the product requested.
B. For combination products: Individual must try two formulary products:
One of which must be in the same specific class as at least one ingredient in non-formulary combination product.
C. For Non-Formulary antibiotics/ anti-virals/ anti-fungals, individual has previously tried and
failed one formulary antibiotic/ anti-viral/ anti-fungal product within the same route of
D. The individual has a documented drug interaction
E. The individual has documented adverse drug experiences (side effects, adverse drug

II. Any request for a Non-Formulary prescription medication that does not meet criteria in section I shall be subject to the normal medical necessity review. Source

Alternatives to Flomax???

medical news
Flomax, the branded version of the drug tamsulosin, is often prescribed to relieve the symptoms of BPH. benign prostatic hyperplasia
Flomax can cost more than $200 per month and might not be entirely covered by insurance. Flomax may be no more effective than other alpha-blockers, but the manufacturing company spends more than $100 million marketing it to consumers, so it is often the only BPH drug many people know about.
A generic form of Flomax, called doxazosin, may cost as little as $10 per month.

 “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:

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 Maximum.


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…

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:

Peter Lee did threaten to terminate agents that did phony special enrollments. Please note though that the main thing I learned in my one year of law school and CPCU was that you must read a law 3 times and then when you think you understand it, read it again. I’ve only read the 12 pages, one time.


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. special-enrollment-periods/

Please note also, if there are non owner or spousal employees, you would then qualify for a Group Plan

Get Quotes for Groups here

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?


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  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.

President Trump Insurance is very complicated  trump-healthcare-complicated-budget-video




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).  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


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.   Well Rx Video – save $$$

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

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.

5 comments on “Prescriptions Drugs – Rx – Including under 65 ACA

  1. My 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 above. 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.

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