What can you do if your drug is not on the drug list or if the drug is restricted in some way?

If your drug is not on the drug list (formulary) or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug. This will give you and your doctor time to change to another drug or to file an exception.
    Note: Only members in certain situations can get a temporary supply (see below).
  • You can change to another drug.
  • You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

For more information, view Blue Shield of California Promise Health Plan Medication transition policy.

Temporary supply requirements

Under certain circumstances, the Blue Shield Promise Medicare Plan can offer a temporary supply of a drug you need. Doing this gives you time to talk to your doctor about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

  1. The change to your drug coverage must be one of the following types of changes:
    • The drug you have been taking is no longer on the plan's drug list (formulary).

    or

    • The drug you have been taking is now restricted in some way (Chapter 5, Section 4 in the Evidence of Coverage (EOC) tells about restrictions).
  2. You must be in one of the following situations described below:
    • For members who were in the plan last year and affected by the drug coverage changes described above:

      We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

    • For new members affected by the drug coverage changes described above:

      We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.

    • For those who have been members of the plan for more than 90 days, reside in a long-term care facility, and need a supply right away:

      We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.

If you don't have prescription drug coverage (Medicare Part D), you can find a prescription drug plan online using the Medicare Prescription Drug Plan Finder

Using the Finder, you can conduct a general or personalized plan search. A personalized search may provide you with more accurate cost estimates and coverage information.