Drug Formulary and Part D Prescription Drug Information

What is the Blue Shield of California Promise Health Plan Comprehensive Formulary?

A formulary is a list of health plan-covered drugs

A formulary is a list of covered drugs selected by Blue Shield of California Promise Health Plan in consultation with a team of health care providers. The list of drugs represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Shield of California Promise Health Plan comprehensive formulary lists drugs that members can get.

Blue Shield Promise Cal MediConnect Plan covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Your co-payment amount will vary from $0 to $8.50 per drug depending your income.

Blue Shield Promise Cal MediConnect Plan also covers certain Non-Part D / over-the-counter (OTC) drugs that are covered. You will pay $0 co-pay for all Non-Part D / OTC drugs that are covered. Please refer to the Blue Shield Promise Cal MediConnect Plan Drug Formulary below for the covered Non-Part D / OTC drugs (see Tier 3 drugs).

Requesting an Exception

An exception is a permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered drugs, or is not covered in the way you would like, you can ask us to make an "exception".

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the "exception". For more information please review your Evidence of Coverage (EOC) document, Chapter 9 Section 6.2.

For instructions on how to submit a coverage decision review the page here. To submit Part D Coverage decision online fill out the form here.


Prescription drug reimbursement form

Use the Direct Member Reimbursement (DMR) form below to submit a claim to be reimbursed for a prescription you paid out of pocket for at a non-participating pharmacy.

Direct Member Reimbursement Form CMC

English | Spanish

Limitations, copays, and restrictions may apply. For more information, call Blue Shield Promise Cal MediConnect Plan Member Services or read the Blue Shield Promise Cal MediConnect Plan Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or co-payments may change from time to time throughout the year and on January 1 of each year. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook

Online Formulary Search

Our drug list is updated monthly. For the most current list of drugs on the formulary, please click on the "Search Drug Formulary" button, below, or call Member Services at
(855) 905-3825, TTY users should call: 711,
8:00 a.m. to 8:00 p.m. seven days a week.

Search Drug Formulary

Blue Shield Promise Cal MediConnect Plan Drug Formulary Printed documents (in PDF format)

All printed documents (in PDF format) listed in this section are Approved HPMS Formulary ID 19463, Version 23, and are available for download below:

Request a copy of the Drug Formulary




Blue Shield of California Promise Health Plan contracts with pharmacies that equal or exceed CMS requirements



Material ID: H0148_19_028_WEB
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