Understanding Medicare Advantage Prescription Drug and Medicare Prescription Drug Plans
What is Medicare Part D?
Medicare Part D was added to help individuals pay for prescription drugs. Signing up for Medicare Part D is voluntary, although penalties may apply if you don't sign up when you're first eligible and if you don’t have other drug coverage that is equal to or better than the coverage offered by Medicare. (This is known as creditable coverage.)
Who is eligible?
To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B. For prescription drug coverage through a Medicare Advantage plan, you must have both Medicare Part A and Part B to enroll. You must continue to pay your Medicare Part B premium.
What is the “coverage gap”?
Most Medicare Prescription Drug Plans have a coverage gap. This means that after you and your plan have spent a certain amount of money (this is called the "initial coverage limit" and may vary by plan) for covered drugs, you pay a different cost-sharing amount for your drugs while you are in the coverage "gap."
In addition, when you are in the coverage gap stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs.
Read your plan Summary of Benefits or Evidence of Coverage for more information on each plan's coverage through the gap. Once you reach the gap limit, you will then receive "catastrophic coverage."
In 2024, the coverage gap begins once your total drug costs reach $5,030.
What is catastrophic coverage?
Catastrophic coverage is special coverage for people who have extremely high drug costs. Once you or other qualified parties on your behalf have paid more than $8,000 in 2024 for your covered drugs, you pay nothing for the rest of the year.
Which drugs are covered?
All of Blue Shield's Medicare Advantage Prescription Drug and Medicare Prescription Drug Plans include a formulary (list of covered drugs) that have been approved by the Centers for Medicare and Medicaid Services. Please review the appropriate plan formulary to make sure it includes the prescription drugs you need before choosing a plan. If you cannot find your drug on our formulary, ask your doctor or other prescriber if there is a drug on our formulary that can be prescribed to treat your condition. Find out more about covered drugs in Blue Shield of California’s Formulary for Medicare Part D.
Can I get prescription coverage from Medicare Part A and Part B?
No. Medicare prescription drug coverage is not available directly from Medicare. Although you are able to have your premium deducted from your Social Security check, you must purchase Medicare prescription drug coverage from an insurance company or a private company, such as Blue Shield of California, that has been approved by Medicare to offer Part D prescription coverage.
When can I get Medicare prescription drug coverage?
The next opportunity for Medicare recipients to enroll will be from October 15 to December 7, during open enrollment. This window is available at the same time every year. There are certain circumstances that will allow a Medicare recipient to enroll during a Special Election Period. Call us at (855) 203-3874 (TTY: 711) for more information about Special Election Periods.
If you don't enroll when you're first eligible and you don’t have other creditable coverage, you may have to pay a late-enrollment penalty, which is calculated/charged as at least 1% of the national base beneficiary premium for every month you wait to enroll. If you enroll in the program late, you may have to pay that penalty each month for as long as you stay in a Medicare Part D prescription drug plan.
For an explanation of how to determine your penalty amount for late enrollment, call 1-800-MEDICARE (1-800-633-4227) TTY/TDD 1-877-486-2048, 24 hours a day, seven days a week.
Who can I call at Blue Shield of California to answer additional questions?
Find a list of phone numbers for your particular plan at the Contact us page.
Are any drugs excluded from Medicare Advantage Prescription Drug or Medicare Prescription Drug plans?
A drug is not covered under a Medicare Advantage Prescription Drug Plan or Medicare Prescription Drug Plan if payment for that drug is available under Part A or B of Medicare. For example, a drug cannot be covered if it is administered in a hospital or a physician’s office.
Medicare also excludes drugs from the following categories:
- Drugs not approved by the FDA
- Nonprescription drugs (also called over-the-counter drugs)
- Drugs used to promote fertility
- Drugs used for the relief of cough or cold symptoms
- Drugs used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
- Drugs used for the treatment of anorexia, weight loss, or weight gain
- Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
Note: Costs associated with these drugs will not apply toward your true out-of-pocket expenses (TrOOP). For more information, please refer to the Center for Medicare and Medicaid document Understanding True Out-of-Pocket Costs (TrOOP).
This information is not a complete description of benefits. Contact the Customer Service number on your ID card.
How do I submit reimbursement requests to my Part D plan for prescriptions I paid out-of-pocket for?
As an eligible Medicare Part D member, any time you pay out-of-pocket for a prescription that is covered under your pharmacy benefit plan, you can submit a request for reimbursement.
The reimbursement form must be received within three years from the date you paid for the service. This process of reimbursing is called direct member reimbursement or DMR.
Submission of the form is not a guarantee of payment. Reimbursement requests will not be processed without a prescription receipt.
If you need help completing the DMR form, please contact your pharmacist or call the Customer Service number on your Blue Shield ID card.
DMR form for Medicare members, English (PDF, 233 KB)
DMR form for Medicare members, Español (PDF, 144 KB)
Mail the completed DMR form to:
Blue Shield of California
P.O. Box 52066
Phoenix, AZ 85072-2066
How to use your Blue Shield of California Medicare formulary
What is a formulary?
Each Medicare Advantage Prescription Drug Plan and Medicare Prescription Drug Plan includes a list of drugs it covers. This list is called a formulary. At Blue Shield of California, the formulary is developed and maintained by the Pharmacy and Therapeutics (P&T) committee and contains medications that have been reviewed and approved by the Food and Drug Administration (FDA). The Blue Shield of California P&T Committee includes practicing physicians and clinical pharmacists. The committee reviews and updates the formulary at least quarterly to assist physicians in prescribing medically appropriate and cost-effective medications.
What is a coverage decision?
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medications. Exceptions and prior authorizations are types of coverage decisions you can ask for.
Blue Shield of California drug coverage requirements are determined by our Pharmacy & Therapeutics (P&T) Committee, based on review of the medical evidence, expert consultation, and nationally recognized treatment guidelines, and are made in consideration of regulatory requirements for coverage decisions.
If your Medicare Part D formulary indicates that your drug has a drug requirement/limitation (prior authorization or step therapy) for coverage, you can view the criteria that Blue Shield of California will use to make a coverage decision. The requirement must be met before coverage will be authorized.
What is a drug prior authorization and how does it work?
Prior authorization (prior approval) may be required for coverage of certain drugs. This means that you, your doctor, other prescriber, or appointed representative will need to contact Blue Shield of California to request prior authorization for coverage of your prescription and to provide clinical information. If the necessary information is not submitted or the information does not meet the prior authorization criteria, the drug may not be covered.
What is step therapy and how does it work?
Step therapy requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first. If drug A does not work for you, we will then cover drug B. Our drug claims processing system will automatically look for a previous drug A claim when you submit a claim for drug B.
How can I view the prior authorization or step therapy requirements for a drug in a Blue Shield Medicare formulary?
Visit the Formulary page. and select a Medicare plan. This will take you to the plan formulary search tool.
There are two ways to view prior authorization and step therapy requirements:
- Enter the drug name you are looking for in the “Drug Name Search” section of the formulary tool and check the “Limits & Restrictions” column to see if Prior Authorization (PA) or Step Therapy (ST) symbols appear.
- Click the “Prior Authorization Criteria” or “Step Therapy Criteria” links to download the PDF. Search for the criteria by the generic or brand name of the drug to view the drug coverage requirements for that drug.
What if my drug is not listed on the Blue Shield of California formulary?
Once you're a Blue Shield member, if you learn that your selected plan does not cover your drug, you have two options:
- Ask Customer Service for a list of similar drugs that are covered by the plan you selected. When you receive the list, show it to your doctor and ask them to prescribe a similar drug that is covered by the plan you selected.
- Request that Blue Shield of California make an exception and cover your drug. Visit the Coverage decisions page for more information on how you or your physician can submit an exception request for your drug.
How long does a coverage decision review take?
If a doctor's office calls Blue Shield of California with all of your information, including your name, subscriber ID number, clinical diagnosis, past drug history, and other clinical information required in our prior authorization criteria for the drug, we can review the request during the call. If a request is faxed or submitted electronically (also ePA), it may take up to 72 hours (or 24 hours for expedited requests) to make a coverage decision depending on whether we receive completed information in the fax or electronic request.
How do I check the status of a coverage decision (prior authorization or exception request)?
You can call your doctor's office or call the Customer Service number on your ID card.
Part D late-enrollment penalty information
What is the Part D late-enrollment penalty and who has to pay it?
A person enrolled in a Medicare Advantage Prescription Drug Plan or Medicare Prescription Drug Plan may owe a late-enrollment penalty if they go without Part D or other creditable prescription drug coverage for any continuous period of 63 days or more, after the end of his or her Initial Enrollment Period for Part D coverage.
Generally, the late-enrollment penalty is added to the person’s monthly Part D premium for as long as they have Medicare prescription drug coverage, even if the person changes his or her Medicare Advantage Prescription Drug Plan or Medicare Prescription Drug Plan. The late-enrollment penalty amount changes each year. The cost of the late-enrollment penalty depends on how long the person went without Part D or other prescription drug coverage.
How can I avoid the late-enrollment penalty?
- Join a Medicare drug plan when you're first eligible for Medicare. You won't have to pay a penalty, even if you've never had prescription drug coverage before.
- Don't go 63 or more consecutive days without a Medicare drug plan or other creditable drug coverage. Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or health insurance coverage. Your plan must tell you each year if your drug coverage is creditable coverage. They may send you this information in a letter or draw your attention to it in a newsletter or other piece of correspondence. Keep this information, because you may need it if you join a Medicare drug plan later.
- Keep records showing when you had creditable drug coverage, and tell your plan about it. When you join a Medicare drug plan, the plan will check to see if you had creditable drug coverage for 63 days or more in a row. If the plan believes you didn't, it will send you a letter with a form asking about any drug coverage you had. Complete the form and return it to your drug plan by the deadline in the letter. If you don't tell the plan about your creditable drug coverage, you may have to pay a penalty.
How do I know if my prior prescription drug coverage met Medicare’s minimum standards?
Most plans that offer prescription drug coverage, like plans from employers or unions, must send their members a notice explaining how their prescription drug coverage compares to Medicare prescription drug coverage. This notice tells you if the prescription drug coverage you had through your prior plan was "creditable prescription drug coverage," which means that it met Medicare’s minimum standards. If you didn’t get a separate written notice, your plan may have provided this information in its benefits handbook. If you don’t know whether the prescription drug coverage you had met this standard, you should contact your prior plan.
What if I don’t agree with Medicare’s decision to charge me a late-enrollment-penalty (LEP)?
If you don’t join a Medicare Advantage Prescription Drug Plan or Medicare Prescription Drug Plan when you are first eligible, and you don’t have other creditable prescription drug coverage, you may have to pay a late-enrollment penalty. In some cases, you have the right to ask Medicare to review your late-enrollment penalty decision. This is called a reconsideration. For example, you could request reconsideration if you think Medicare did not count all of your creditable coverage or if you didn’t get a notice that clearly explained whether your previous prescription drug coverage was creditable. Other reasons for requesting a reconsideration are listed on the request form sent with this notice.
Who can I ask for a reconsideration?
You or someone you name to act for you (your representative) can ask for a reconsideration. If someone requests a reconsideration for you, they must send proof of their right to represent you along with the request form. Proof could be a power of attorney form, a court order, or an appointment of representative form. You also can call the Medicare helpline at (800) MEDICARE (800-633-4227) / TTY: (877) 486-2048 and ask for Form CMS-1696, the appointment of representative form.
If you have questions about the information in this form or the late-enrollment penalty (would like to complete this form over the telephone), call the Blue Shield of California Customer Service number on your ID card.
Resources and benefits for Blue Shield of California Medicare Advantage – Prescription Drug Plan members
What durable medical equipment is covered through my plan?
Durable medical equipment (DME) is a type of medical equipment that your doctor orders for medical reasons. Examples of durable medical equipment are walkers, wheelchairs, and hospital beds.
Equipment covered by Blue Shield Medicare Advantage – Prescription Drug Plans include, but are not limited to:
- Hospital bed
- IV infusion pump
- Oxygen equipment
Generally, Blue Shield of California Medicare plans cover any durable medical equipment covered by Original Medicare from the brands and manufacturers on our list. We will not cover other brands and manufacturers unless your doctor or other provider tells us that the brand is appropriate for your medical needs.
Information for new Blue Shield of California Medicare Advantage – Prescription Drug Plan members
If you are new to a Blue Shield of California Medicare Plan and are using a brand of durable medical equipment (DME) that is not on our list, we will continue to cover this brand DME for you for up to 90 days. During this time, you should talk with your doctor to decide what brand DME is medically appropriate for you after this 90-day period. (If you disagree with your doctor, ask them to refer you for a second opinion.)
If you are new to a Blue Shield of California Medicare Plan and are using a prescription drug that is not our formulary (list of covered drugs), we will cover a temporary 30-day supply (31-day supply if you are in a long-term care facility) for you within your first 90 days of new membership. During these 90 days, you should talk with your doctor to determine if another drug is appropriate for you. If you disagree, you may request a coverage decision.
Plan coverage decision
If you (or your provider) don’t agree with Blue Shield of California Medicare Advantage Health Plan’s coverage decision, you, your representative, or your provider may file an appeal. You can also file an appeal if you don’t agree with your provider’s decision about what product or brand is appropriate for your medical condition.
For more information about appeals, see Chapter 9 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”.
NOTE: Authorization rules for services may apply. For details, call the Customer Service number on your ID card.
How am I covered for diabetes supplies?
Blue Shield of California Medicare Plans cover blood glucose monitors and test strips. Please see your plan below for more information on which blood glucose monitors and test strips are preferred.
This brings you the benefits of up-to-date technology such as:
- Ease of use, no coding meters required
- Virtually pain-free testing using the world’s smallest blood sample size
- Increased flexibility to test glucose at more body sites
- 24-hour meter training and technical support
Blue Shield of California Medicare Plans cover meters and test strips. Pricing and amounts vary by plan and preferred vendor.
For the Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield Inspire (HMO) Plan, Blue Shield 65 Plus Choice Plan (HMO), Blue Shield Enhanced (HMO), and Blue Shield Select (PPO) refer to the following for more information:
For the Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield TotalDual Plan (HMO D-SNP), and Blue Shield Inspire (HMO D-SNP), refer to the following for more information:
If you have any other questions, call the Blue Shield Medicare Advantage Customer Service number on your ID card.
Once I’m a member, can I use the same pharmacy I’ve been using to get my prescription drugs?
Blue Shield of California has an extensive network of pharmacies. Check our pharmacy directory to confirm that your pharmacy is part of our network.
Do I need to use my ID card every time I visit the pharmacy?
Always bring your plan ID card with you to the pharmacy to ensure you get the most out of your drug coverage. You should present the card even if your plan has a deductible, where you might be paying 100 percent for the drug. This will allow you to receive Blue Shield's contracted rate at the pharmacy and ensures that your payment will be included in your annual out-of-pocket expenses.
Can I get prescriptions mailed to me?
When you enroll in a Blue Shield of California Medicare plan, your coverage provides a mail service benefit that offers cost savings and the convenience of home delivery.
Once your plan year begins, you will have access to this benefit.
What are my rights and responsibilities if I want to leave a Blue Shield Medicare Advantage HMO, HMO D-SNP, PPO, or Medicare Prescription Drug Plan?
The chapter “Ending your membership in the plan” in the plan’s Evidence of Coverage includes important topics like:
- When you can end your membership
- How to end your membership
- Why Blue Shield might need to end your membership in the plan
Ending your membership in a Blue Shield plans may be voluntary (your own choice) or involuntary (not your own choice). A few important things to know about leaving a plan:
1. You might leave our plan because you decided that you want to leave.
The process for voluntarily ending your membership depends on what type of new coverage you are choosing. If you are enrolling in another plan with prescription drug coverage, simply enrolling in that other plan will end your membership in our plan.
For Medicare Advantage Prescription Drug and/or Medicare Prescription Drug Plans, however, there are some important dates to know. The most common is the Annual Enrollment Period, from October 15 to December 7.
During this time, Medicare Advantage Prescription Drug and/or Medicare Prescription Drug plan enrollees may enroll in another Medicare Advantage Prescription Drug and/or Medicare Prescription Drug Plan or disenroll from their Medicare Advantage Prescription Drug and/or Medicare Prescription Drug Plan and return to Original Medicare. Individuals may make only one election during the Annual Enrollment Period.
For questions about leaving our plan, please call the Customer Service number on your ID card.
2. There are also limited situations where you do not choose to leave, but we are required to end your membership.
For example, if you move out of our service area or you do not stay continuously enrolled in Medicare Part A and Part B.
If you are leaving our plan, you must continue to get your medical care and/or prescription drugs through our plan until your membership ends.
3. We cannot ask you to leave our plan for any reason related to your health, and if we end your membership in our plan, we must tell you our reasons in writing for ending your membership.
We must also explain how you can make a complaint about our decision to end your membership.
Where can I find more Medicare resources?
Start on our Resources page which has useful links to plan documents and other member resources. If you’re already a Blue Shield member, log into your account for personalized information on your benefits.
You can contact Centers for Medicare and Medicaid Services for information on official government services.
Visit www.medicare.gov or call (800) MEDICARE (800-633-4227) / TTY: (877) 486-2048, 24 hours a day, seven days a week.
Health Insurance Counseling and Advocacy Program (HICAP)
The program provides free advice to people with Medicare.
Phone: (800) 434-0222 / TTY: (800) 735-2929
Monday through Friday, 9 a.m. to noon and 1 p.m. to 5 p.m. (PST)
Blue Shield of California
Explore Blue Shield of California plan options now. You can find out what plans are in your area and how much you might expect to pay for each.
You can also talk to your local broker or one of our Blue Shield Medicare advisers.
Phone: (800) 963-8008 (TTY: 711)
Hours: April 1 through September 30: 8 a.m. to 8 p.m., weekdays and October 1 through March 31: 8 a.m. to 8 p.m., seven days a week.
Note: To view the PDF documents on this page you’ll need Adobe Reader.
How can Medicare Advantage Prescription Drug Plans cost $0? What’s the catch?
Medicare Advantage Plans replace Original Medicare benefits, which you have contributed to in the form of payroll taxes. When you choose a Medicare Advantage plan, you transfer your benefit to an insurer like Blue Shield of California. So we are reimbursed by the government and use that payment for your coverage with in-network providers.
Y0118_23_379A1_M Accepted 10222023
H2819_23_379A1_M Accepted 10222023
Page last updated date 10/27/2023