Blue Shield 65 Plus (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Blue Shield 65 Plus (HMO) by California Physicians' Service. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a California Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Blue Shield 65 Plus (HMO)(H0504-017) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. 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 $4660 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" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. California Physicians' Service 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 above the chart.



Plan Overview

Plan Name:Blue Shield 65 Plus
Plan ID: H0504-017
Provider: California Physicians' Service
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:California
Similar Plan:H0504-021


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2$10$18NANN
Baclofen
2$10$18NA16/1NN
Balsalazide Disodium
2$10$18NANN
Balversa
533%33%NA1/1YN
Balziva
2$10$18NANN
Baqsimi
3$40$47NA2/30NN
Baraclude
533%33%NA21/1NN
Baxdela
533%33%NA28/30YN
Bcg Vaccine
3$40$47NANN
Benazepril Hydrochloride And Hydrochlorothiazide
1$0$5NANN
Benznidazole
4$95$100NA240/365NN
Benztropine Mesylate
2$10$18NANN
Bepotastine Besilate
4$95$100NANN
Berinert
533%33%NAYN
Besremi
533%33%NA2/28YN
Betamethasone Dipropionate
2$10$18NANN
Betamethasone Valerate
2$10$18NANN
Betaxolol Hydrochloride
2$10$18NANN
Bethanechol Chloride
2$10$18NANN
Betoptic S
3$40$47NANN
Bevespi Aerosphere
3$40$47NA1/28NN
Bexarotene
533%33%NA10/1YN
Bexsero
3$40$47NANN
Bicillin C-r 900/300
4$95$100NANN
Bicillin Cr
4$95$100NANN
Bicillin L-a
4$95$100NANN
Biktarvy
533%33%NA1/1NN
Bisoprolol Fumarate
2$10$18NANN
Bisoprolol Fumarate And Hydrochlorothiazide
1$0$5NANN
Bivigam
533%33%NAYN
Blisovi 24 Fe
4$95$100NANN
Blisovi Fe 1.5/30
2$10$18NANN
Boostrix
3$40$47NANN
Bosulif
533%33%NA1/1YN
Braftovi
533%33%NA6/1YN
Breo Ellipta
3$40$47NA60/30NN
Breztri
3$40$47NA1/30NN
Briellyn
2$10$18NANN
Brilinta
3$40$47NA2/1NN
Brimonidine Tartrate
2$10$18NANN
Brinzolamide
3$40$47NANN
Briviact
533%33%NA20/1NY
Budesonide
533%33%NA1/1YN
Bumetanide
2$10$18NANN
Buprenorphine
4$95$100NA4/28YN
Buprenorphine And Naloxone
2$10$18NA2/1NN
Buprenorphine Hcl
2$10$18NA21/90NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2$10$18NA3/1NN
Bupropion Hydrochloride
2$10$18NA1/1NN
Buspirone Hydrochloride
2$10$18NANN
Butalbital And Acetaminophen
4$95$100NA48/30YN
Butalbital, Acetaminophen And Caffeine
3$40$47NA48/30YN
Butalbital, Acetaminophen, Caffeine And Codeine Ph
2$10$18NA48/30YN
Butalbital, Aspirin, And Caffeine
3$40$47NA48/30YN
Butalbital, Aspirin, Caffeine And Codeine Phosphat
4$95$100NA48/30YN
Butorphanol Tartrate
3$40$47NA15/28NN
Byetta
4$95$100NA/28NN
Bylvay
533%33%NA5/1YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0504-017

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 $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

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 2023 is $505. 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 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 Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred 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 plan's 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.

Last updated on

Source:CMS Formulary Data Q4 2022
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.

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