About medication policy

Medication policy (Injectable, Implantable, w/DME) is used to determine if a service associated with a medication will be covered by a Blue Shield of California plan. At Blue Shield of California, medication policies are determined by the Pharmacy & Therapeutics (P&T) Committee based on review of the medical evidence, expert consultation, consensus guidelines, community best practices, and are made in consideration of regulatory requirements for coverage determinations. 

To ensure that medication policies (Injectable, Implantable, w/DME) are routinely updated, each will be reviewed on a regular schedule. However, it may be necessary for a policy to be updated more frequently should changes be warranted. Such updates could be a result of, but not limited to, changes in approved indications by the FDA or publication of medical literature showing new clinical data. 

The Blue Shield of California P&T Committee is the governing committee responsible for oversight and approval of policies and procedures concerning formulary management, drug utilization, pharmacy-related quality improvement, educational programs, and other medication matters pertaining to patient care. 

The P&T Committee meets quarterly with members of active practicing network physicians and pharmacists skilled in evidence-based decision making. No voting member of the P&T Committee is employed by Blue Shield. The P&T Committee provides a forum for practitioners in the community and the clinical staff of Blue Shield to discuss current issues in the healthcare industry that affect coverage policies. The committee reviews newly FDA-approved drugs; new FDA approved indications for older drugs, and medical necessity criteria prior authorization of prescription drugs.