How does your Provider ask for medications not approved by your Health Care Plan?
Sometimes, your doctor may need to prescribe a medication that is not on the formulary. Your doctor must contact Blue Shield of California Promise Health Plan to get an okay.
You can also call Blue Shield of California Promise Health Plan Member Services Department toll-free 1-800-605-2556. Blue Shield of California Promise Health Plan will then contact your doctor. To decide if this medication will be covered, Blue Shield of California Promise Health Plan may ask your Provider or the pharmacist (or both) for more information.
You will receive a letter in the mail to let you know if the medication is approved or not approved and if not approved, explaining to you why.
If the medication is approved, you can get the medication at a pharmacy that works with Blue Shield of California Promise Health Plan.
If the medication is not approved, you 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 of California Promise Health Plan formulary
- Limited supply of prescription medications you get from a pharmacy not in Blue Shield of California Promise Health Plan’s network when you have an emergency
- Only non-prescription medications or over-the-counter medications (such as cough/cold syrups, or aspirin) listed on the Blue Shield of California Promise Health Plan 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 on the Blue Shield of California Promise Health Plan 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 of California Promise Health Plan
- 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 the 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 at (866) 820-6009 (Los Angeles County) or (855) 699-5557 (San Diego County) if you have questions about your benefits. The call is free. We are available Monday through Friday, 8:00 a.m. to 6:00 p.m. For emergencies, you can call this number 24 hours a day, 7 days a week.