Covered California Prescription Drug Resources by Health Plan
The table below shows where to find the prescription drug list (or formulary) and customer service phone number for each Covered California health insurance plan.
|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||(800) 788-2949|
|Molina Healthcare||Formulary||(888) 858-2150|
|Oscar Health Plan of California||Formulary||(855) OSCAR-55
Ext. 1, Ext. 2
|Sharp Health Plan||Formulary||(800) 359-2002|
|Valley Health Plan||Formulary||(888) 421-8444|
|Western Health Advantage||Formulary||(888) 563-2250|
The Patient Protection and Affordable Care Act requires health insurance plans to cover prescription drugs (also known as prescription medications). This means prescription drugs will be available to enrolled members of a health plan at reduced or no charge. The set of prescription drugs covered by a health insurance plan may also be called a formulary, prescription drug list, outpatient prescription drug list or select drug list. (Plans do not cover every prescription drug available, but are subject to regulations that require drug coverage in major drug categories.)
All Covered California health insurance plans will:
- Use the same names for drug tiers. No matter which health plan you choose, the drugs will be labeled as Tier 1 (generic drugs), Tier 2 (preferred drugs), Tier 3 (non-preferred drugs) or Tier 4 (specialty drugs).
- 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.
- Maintain a dedicated prescription drug customer service line where current and prospective members can call for help.
- Describe the appeals and exception process clearly on the formulary, so members understand what to do if a drug they need is not covered.
Provide current and prospective members with an estimate of the out-of-pocket cost for specific drugs.
Prescription Drugs Not Covered by a Health Plan
If a member needs a drug that their health insurance plan does not cover, he or she can refer to the resources above on how to ask for the plan to make an exception and cover the drug. When using the customer service number, it is important to describe the exact Covered California health insurance plan, because health insurance companies have many health insurance products.
In general, members will need to ask a physician to help them ask for an exception. Another option is to ask a physician if alternative drugs that are covered could substitute for the recommended non-covered drug for the member’s situation. If not, a consumer should ask his or her physician if he or she can help file an appeal to get an exception.
Health insurance plan formularies will include drug coverage for most types of conditions. For help talking to a health insurance company, contact the Health Consumer Alliance, which offers free local assistance to Covered California health insurance plan members. Visit the Health Consumer Alliance website or call (888) 804-3536.
In addition, if you are having trouble with your health plan’s prescription drug options that has not been resolved by your plan, you can visit the Department of Managed Health Care Help Center website for help or call (888) 466-2219.
Understanding Covered California Prescription Drug Costs
The table below shows prescription drug costs, according to metal tier, for all 2017 Covered California individual health insurance plans.
|PRESCRIPTION DRUG COST SHARES|
|Coverage Category||Bronze 60||Bronze 60 HDHP||Silver 70||Enhanced Silver 73||Enhanced Silver 87||Enhanced Silver 94||Gold 80||Platinum 90||Minimum
|Covers 60% average annual cost||Covers 60% average annual cost||Covers 70% average annual cost||Covers 73% average annual cost. Eligibility based on income and premium assistance.||Covers 87% average annual cost. Eligibility based on income and premium assistance.||Covers 94% average annual cost. Eligibility based on income and premium assistance.||Covers 80% average annual cost||Covers 90% average annual cost|
|Generic Drugs (Tier 1)||100% up to $500 per prescription||40% up to $500 per prescription||$15||$15||$5||$3||$15||$5||100% until consumer spends $7,150 for all medical expenses|
|Preferred Drugs (Tier 2)||100% up to $500 per prescription||40% up to $500 per prescription||$55||$50||$20||$10||$55||$15||100% until consumer spends $7,150 for all medical expenses|
|Nonpreferred Drugs (Tier 3)||100% up to $500 per prescription||40% up to $500 per prescription||$80||$75||$35||$15||$75||$25||100% until consumer spends $7,150 for all medical expenses|
|Specialty Drugs (Tier 4)||100% up to $500 per prescription||40% up to $500 per prescription||20% up to $250 per prescription||20% up to $250 per prescription||15% up to $150 per prescription||10% up to $150 per prescription||20% up to $250 per prescription||10% up to $250 per prescription||100% until consumer spends $7,150 for all medical expenses|
|PLAN FEATURES THAT MAY APPLY|
The dollar amounts are the member’s costs of copays, and the percentages are the coinsurance costs. If a drug is subject to a deductible, the enrollee must meet that deductible cost before the copay or coinsurance amount applies. (The Bronze HDHP plan prices differ from the Bronze information below.)
Tier 4 (specialty drugs) have a limit on how much a member will pay for a 30-day drug supply. This is true for all metal tiers. It is important to note that there is a pharmacy deductible of $500 on the Bronze tier and a $250 drug deductible on the Silver tier, which means that an enrollee must fulfill the deductible before paying the coinsurance amount for the drug up to the cost-share limit for the metal tier ($500 for Bronze and $250 for Silver).
In addition, the out-of-pocket maximums are included. The health insurance company will pay 100 percent of the cost of the covered drug once the enrollee has paid this amount toward any in-network covered health service, including prescription drugs. To receive drugs at the prices below, a member would need to receive them through a pharmacy or a mailing order program that is offered by their specific health insurance plan. In most cases, information on participating pharmacies is also included on the health insurance plan website. If not, a consumer may call the customer service line to check whether the pharmacy is a participating pharmacy.
Brand-name drugs have been developed by a company that holds the legal rights to sell them. When those rights expire, other drug companies can make a copy of the brand drugs (generics). Brand-name drugs may be more familiar to a consumer because they are advertised more frequently. Also, brand-name drugs are usually more expensive than generics.
Generics are either copies of brand-name drugs or are brand-name drugs with patents that have expired. Brand-name and generic drugs have the same active ingredients, strength and dose. The U.S. Food and Drug Administration (FDA) requires that generic drugs meet the same high standards for purity, quality, safety and strength. Generic drugs are almost always less expensive than brand-name drugs.
Preferred, Non-Preferred and Specialty Drugs
Health insurance plans often structure their formularies into pricing groups. Some drugs are in lower-priced groups and cost consumers less money. Other drugs are in higher-priced groups and cost consumers more money. Preferred drugs are usually the cheapest for the consumer and the insurance company. Non-preferred and specialty drugs are the most expensive, both for the consumer and the insurance company.
Some health insurance plans refer to the "Select Drug List" or "drug tiers" in their formulary. The Select Drug List is a list of brand-name and generic drugs that have been approved by the FDA and have been reviewed and recommended for their quality.
Some health insurance plan formularies refer to FDA drug tiers. Drugs on the FDA Select Drug List are grouped into tiers. Several factors determine which tier a drug is placed in. These factors include:
- The cost of the drug.
- The cost of the drug in comparison to other drugs used for the same type of treatment.
- The availability of over-the-counter options.
- Other clinical and cost factors.
Prescription drug lists are changed frequently. For the most current information, a consumer should confirm coverage and out-of-pocket cost with their specific health insurance plan before filling prescriptions.
Read more about coverage basics: