If you are a new member and are taking a prescription drug that is not in your plan formulary, you will need to follow our medication transition process. Learn about your options in this process in this section. You can also read our Transition Policy.
What to do if your drug is not in the formulary or if the drug is restricted in some way
If your drug is not on the approved list of drugs or is restricted:
- 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.
- 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)
Temporary supply requirements
Under certain circumstances, your Blue Shield of California Medicare plan can offer a temporary supply of a drug you need. Doing this gives you time to talk to your doctor about available alternatives.
To be eligible for a temporary supply, you must meet both requirements:
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).
- 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:
For members who were in the plan last year and affected by the drug coverage:
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 allow multiple refills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Long-term care pharmacies may provide the drug in smaller amounts to prevent waste.)
For new members affected by drug coverage changes:
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 allow multiple refills 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), consider if a prescription drug plan is right for you.
Learn more about the Blue Shield transition policy:
Transition policy (117 KB)