MEDICARE DRUG FORMULARY

Each Blue Shield of California Medicare Advantage and Medicare Prescription Drug Plan has a list of drugs it covers. This list is called a formulary. You can access the list of covered drugs in our Medicare Advantage and Medicare Prescription Drug Plans (see Formulary by plan section below). If you have questions about how to better understand your formulary, visit our frequently asked questions. 

How our Medicare formularies work:
Each of the Blue Shield of California formularies contain medications that the Food and Drug Administration (FDA) has reviewed and approved. The Blue Shield Pharmacy and Therapeutics (P&T) Committee develops and updates the formulary regularly to ensure it meets all Medicare requirements for included and excluded drugs. 

The Blue Shield P&T Committee includes physicians and clinical pharmacists from our provider and pharmacy networks. Committee voting members are not  Blue Shield of California employees. To assist physicians in prescribing medically appropriate and cost-effective medications, the P&T Committee reviews: 

• Medical literature
• FDA drug labels 
• National treatment guidelines to update the formulary and drug prior authorization criteria

All recommended changes to Blue Shield of California Medicare formularies and drug prior authorization criteria are first approved by the Centers for Medicare and Medicaid Services (CMS), which provides oversight of the Medicare program.

If your plan does not cover a specific drug, you can ask Blue Shield of California to make an exception to the rules that govern coverage. Visit the Coverage decisions and exceptions page for more information.

Medicare Part B diabetic test strips
Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield Inspire (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield Select (PPO), and Blue Shield Enhanced (HMO) should refer to the following for more information.

Learn about Part B preferred diabetic test strips:

• English (PDF, 110 KB)
• Español (PDF, 112 KB)

Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield TotalDual Plan (HMO D-SNP) in Orange and San Bernardino Counties, Blue Shield Inspire (HMO D-SNP), and Blue Shield TotalDual Plan (HMO D-SNP) in Los Angeles and San Diego counties should refer to the following for more information.

Learn about Part B preferred diabetic test strips:

• English (PDF, 125 KB)
• Español (PDF, 134 KB)

About Part B Step Therapy
If you are enrolled in a Blue Shield Select (PPO) or Blue Shield Medicare (PPO) plan, your Part B drugs may be subject to step therapy.

View the Part B Step Therapy criteria:

• English (PDF, 200 KB)
• Español (PDF, 240 KB)

Important message about your costs for vaccines and insulin:

• What you pay for Paxlovid – our plan covers Paxlovid at no cost to you, even if you have not met your deductible, if applicable.
• What you pay for vaccines – our plan covers most Part D vaccines at no cost to you, even if you have not met your deductible, if applicable.
• What you pay for insulin – you won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you have not met your deductible, if applicable.

Part B Inflation Rebate Program:

The list of Medicare Part B rebatable drugs and adjusted coinsurance amounts for these drugs are published quarterly by the Centers for Medicare and Medicaid Services (CMS). 

View the current Part B rebatable drug coinsurance rates:

• English (PDF, 180 KB)
• Español (PDF, 210 KB)