Sometimes, your doctor may need to prescribe a medication that is not on the list of covered drugs / formulary. In that case, your doctor must contact Blue Shield of California Promise Health Plan to get approval called “prior authorization”.

To request a prescription drug prior authorization, call the Blue Shield Promise Medi-Cal Member Services Department:

Los Angeles County phone:(800) 605-2556 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday

San Diego County phone:(855) 699-5557 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday

Blue Shield Promise Medi-Cal will then contact your doctor. In order to help determine whether this medication will be covered. Blue Shield Promise Medi-Cal may ask your provider or the pharmacist (or both) for more information.

You will receive a letter in the mail notifying you whether the medication is approved or not approved.

  • If the medication is approved, you can get the medication at a pharmacy that works with Blue Shield of California Promise Health Plan.
  • If not approved, the letter will explain why. You will also have the right to appeal the decision. An appeal is when you want a decision to be reviewed. See the Blue Shield Promise Medi-Cal Member Handbook (Evidence of Coverage) for your county for more information about appeals.

What medications are covered?

You can get the following medications and other items when they are prescribed by your doctor and are medically necessary:

  • Prescription medications listed on the Blue Shield Promise Medi-Cal formulary
  • Limited supply of prescription medications you get from a non-network pharmacy when you have an emergency
  • Non-prescription medications or over-the-counter medications (such as cough/cold syrups, or aspirin) that are listed on the Blue Shield Promise Medi-Cal formulary
  • Formulary diabetic supplies: insulin, insulin syringes, glucose test strips, lancets and lancet puncture devices, pen delivery systems, blood glucose monitors including monitors for the visually impaired, and ketone urine testing strips
  • FDA-approved birth control devices, birth control pills, diaphragms, condoms, and contraceptive jellies that are listed on the Blue Shield Promise Medi-Cal formulary
  • Anti-rejection medication for up to two years following an organ transplant, unless during that period the member:
    • Has private health insurance, or
    • Becomes eligible for Medicare or private health insurance covering the medication
  • Emergency contraception
  • EpiPens, Ana-kits, peak flow meters, and spacers

What medications are not covered?

  • Medications from a non-network pharmacy, except medications needed because of an emergency or out-of-area care
  • Non-formulary medications, except with an okay from Blue Shield Promise Medi-Cal
  • Medications that are experimental or investigational in nature, except in certain cases of terminal illness. If you have been denied an experimental or investigational medication, you have the right to request an Independent Medical Review (IMR). You can learn more about this in the "Complaints: What should I do if I am unhappy?" section of your Member Handbook.
  • Cosmetic medications, except as prescribed for medically necessary conditions
  • Non-formulary dietary or nutritional products, except when medically necessary or for the treatment of Phenylketonuria
  • Any injectable medication that is not medically necessary and not prescribed by a doctor
  • Appetite suppressants, except as medically necessary for morbid obesity
  • Compounded medications with formulary alternatives, or those with no FDA-approved indications

Call Blue Shield of California Promise Health Plan, if you have questions about your benefits. The call is free.

Los Angeles County phone:(800) 605-2556 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday

San Diego County phone:(855) 699-5557 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday