Medicare Drug Formulary

Go to 2025 Medicare Drug Formulary Page

Each Blue Shield of California Medicare Advantage and Medicare Prescription Drug Plan has a list of drugs it covers. This list is called a formulary. You can access the list of covered drugs in our Medicare Advantage and Medicare Prescription Drug Plans (see Formulary by plan section below).  

How our Medicare formularies work:

Each of the Blue Shield of California formularies contain medications that the Food and Drug Administration (FDA) has reviewed and approved. The Blue Shield Pharmacy and Therapeutics (P&T) Committee develops and updates the formulary regularly to ensure it meets all Medicare requirements for included and excluded drugs. 

The Blue Shield P&T Committee includes physicians and clinical pharmacists from our provider and pharmacy networks. Committee voting members are not  Blue Shield of California employees. To assist physicians in prescribing medically appropriate and cost-effective medications, the P&T Committee reviews: 

• Medical literature
• FDA drug labels 
• National treatment guidelines to update the formulary and drug prior authorization criteria

All recommended changes to Blue Shield of California Medicare formularies and drug prior authorization criteria are first approved by the Centers for Medicare and Medicaid Services (CMS), which provides oversight of the Medicare program.

If your plan does not cover a specific drug, you can ask Blue Shield of California to make an exception to the rules that govern coverage. Visit the Coverage decisions and exceptions page for more information.

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 Food and Drug Administration (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 Centers for Medicare and Medicaid Services (CMS) 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.

Medicare Part B diabetic test strips

Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield Inspire (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield Medicare (PPO), and Blue Shield Advantage (HMO) should refer to the following for more information.

Learn about Part B preferred diabetic test strips:

• English (PDF, 763 KB)
• Español (PDF, 738 KB)

Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), and Blue Shield TotalDual Plan (HMO D-SNP) in Los Angeles and San Diego counties should refer to the following for more information.

Learn about Part B preferred diabetic test strips:

• English (PDF, 690 KB)
• Español (PDF, 659 KB)

Important message about your costs for vaccines and insulin:

• What you pay for Paxlovid – our plan covers Paxlovid at no cost to you, even if you have not met your deductible, if applicable.
• What you pay for vaccines – our plan covers most Part D vaccines at no cost to you, even if you have not met your deductible, if applicable.
• What you pay for insulin – you won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you have not met your deductible, if applicable.