2020 Blue Shield Promise AdvantageOptimum Plan 2 (HMO) Formulary
Below is the Formulary, or drug list, for Blue Shield Promise AdvantageOptimum Plan 2 (HMO) from Blue Shield Of California Promise Health Plan. A formulary is a list of prescription medications that are covered under Blue Shield Of California Promise Health Plan's
2020 Medicare Advantage Plan in California.
The Blue Shield Promise AdvantageOptimum Plan 2 (HMO) plan has a $0 drug deductible.
The Initial Coverage Limit (ICL) for this plan is $4020. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible)
You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart.
In 2020 if you have spent $6350 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Blue Shield Promise AdvantageOptimum Plan 2 (HMO) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.
|Drugs Starting With Letter:||C|
|Drug Name*Tip Click the Drug name to Compare Coverage From Every Plan In Your Area||Tier Level||Cost Preferred||Cost Non Preferred||Cost Mail||Limit Amount/Days||Prior Auth
|Candesartan Cilexetil And Hydrochlorothiazide||$10||$17||NA||N||N|
|Captopril And Hydrochlorothiazide||$0||$3||NA||N||N|
|Carbidopa And Levodopa||$10||$17||NA||N||N|
|Carbidopa, Levodopa, And Entacapone||$95||$100||NA||N||Y|
|Chlordiazepoxide And Amitriptyline Hydrochloride||$10||$17||NA||N||N|
|Cimetidine Hydrochloride Oral Solution||$10||$17||NA||N||N|
|Clobetasol Propionate (emollient)||$10||$17||NA||N||N|
|Clotrimazole And Betamethasone Dipropionate||$10||$17||NA||N||N|
|Combipatch (estradiol/norethindrone Acetate Transd||$40||$47||NA||N||N|
Coverage Levels for H5928-053
Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4020
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $6350 in 2020.
4.Catastrophic: Anything over $6350 you will receive a significant increase in coverage.
Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2020 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.
What if a drug I need is not listed?
Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.
Source:CMS Formulary Data Oct. 2019
Source:NDC Directory by FDA.gov
**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.