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Pharmacy benefits
Pharmacy benefits
Blue Shield’s pharmacy benefits are fully integrated with the medical benefits, offering you the convenience of one Blue Shield member ID card and one Member Services phone number for pharmacy and medical benefit questions. Visit blueshieldca.com/pharmacy to additional pharmacy benefit information. You can locate a network pharmacy near you by using this pharmacy locator.

When visiting your local retail pharmacy, be sure to present your member ID card to access your pharmacy benefit. Your member ID card contains RxBIN and RxPCN information that is needed by the pharmacy to be able to process your prescription(s). Member ID cards will be updated to include Rx BIN and PCN information for 2021. You will receive your new 2021 member ID card based on your current delivery method preference (via postal mail or digitally). Please refer to the table below to help distinguish between your current 2020 ID card and your new 2021 ID card.
RxBIN RxPCN
2020
600428
191000
2021
004336
7799333
Note: RxBIN and RxPCN information is located on the front of your ID card

Trio HMO, Access+ HMO and EPO CalPERS drug formulary
The Blue Shield Plus Drug Formulary is a list of medications that are approved by the Food and Drug Administration. These medications are eligible for coverage under the Blue Shield outpatient prescription drug benefit. We have a guide to help you select cost-effective drug therapy. The 2020 version is available as a PDF or, if you prefer you can search by brand and generic names here. The 2021 drug formulary is also available as a PDF and by online search here.

You can help lower your out-of-pocket prescription drug costs by requesting formulary generic and formulary brand medications when you see your doctor. These medications are covered at a lower copayment than non-formulary brand drugs. Use this drug cost tool to search for prescription pricing.

If you are taking maintenance drugs to treat a chronic condition, you can receive up to a 90-day supply (for the cost of a 60-day supply) by using select retail pharmacies (Costco, CVS and Safeway/Vons) or our mail service pharmacy, CVS Caremark. To see covered maintenance drugs, refer to the maintenance drug list. For more information about coverage of maintenance drugs, please refer to your Evidence of Coverage.

Compounded drugs
Compounded drugs are mixed by a pharmacy to meet special needs. These types of drugs are not approved by the Food and Drug Administration (FDA) for safety, effectiveness, or quality. Often, you can get other FDA-approved drugs that are covered by your plan at your local retail pharmacy. If your doctor feels a different medication would not work for you, you may begin the process to obtain a drug prior authorization, or your provider can contact Blue Shield’s Pharmacy Services to request one on your behalf. Refer to your Evidence of Coverage for coverage requirements for compounded drugs.

Specialty drugs
Refer to this specialty drug list for specialty drugs that are only available through a Blue Shield network specialty pharmacy.

Flu shots
With your Blue Shield plan, you can get a flu shot at no extra cost to you at your doctor’s office or at any participating network pharmacy, including most major retail chains.

Getting a flu shot is a good idea. This year, amid the COVID-19 pandemic, it’s more important than ever. Contact the pharmacy before you go to find out if they a specific kind of flu shot that you might need, and remember to social distance and wear a cloth face covering. You will likely need to be patient while waiting for your shot. Some locations may experience longer lines than usual due to social distancing measures. These are in place to help protect everyone.
Out-of-pocket expenses
The 2021 annual out-of-pocket maximum for pharmacy expenses is $7,050 for an individual and $14,100 for a family. Additionally, once you have paid $1,000 for formulary mail service prescriptions, you will pay $0 for formulary prescriptions filled at CVS Caremark for the remainder of the year. (Non-formulary brand drugs and drugs to treat sexual dysfunction do not accumulate toward this mail service out-of-pocket maximum.)

Trio HMO, Access+ HMO and EPO CalPERS pharmacy copays

Up to a 30-day supply for most drugs at a network pharmacy
$5 generic
$20 formulary brand
$50 non-formulary brand
$30 specialty
Brand name drugs when generic equivalent is available: $5 plus difference in cost between generic drug and brand name drug.
Specialty drugs are only available through a Blue Shield network specialty pharmacy.
Up to a 30-day supply of maintenance drugs in the first 90 days can be filled at any retail pharmacy.






Up to a 30-day supply of maintenance drugs after the first 90 days can continue to be filled at any retail pharmacy
OR
Switch to a 90-day supply of maintenance drugs from mail service pharmacy or select retail pharmacies for the same copay.
$5 generic
$10 generic
$20 formulary brand
$40 formulary brand
$50 non-formulary brand
$100 non-formulary brand
Brand name drugs when generic equivalent is available: $5 plus difference in cost between generic drug and brand name drug.
Brand name drugs when generic equivalent is available: $5 plus difference in cost between generic drug and brand name drug
Up to a 90-day supply of maintenance drugs from mail service pharmacy and select retail pharmacies: Costco, CVS (including CVS Pharmacy in Target stores) and Safeway/Vons.
Contact us at Shield Concierge
(800) 334-5847
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