External review for approval of a drug your plan doesn't cover

What is this about?

If you requested approval for a prescription drug that your plan doesn't cover and we denied your request, this information tells you how to request an external review.

External Review

If we denied your request to approve a prescription drug that your plan doesn’t cover, you or an authorized representative may be eligible for external review by an independent review organization, or IRO. If applicable, when we notify you of our denial, we’ll also include the form you'll need to fill out and send in to request the review.

If you need a copy of the form, you can download it here:

You'll need to request an external review by an IRO within four months of the date you received our decision.

Before requesting a review, ask your doctor for a written statement explaining why the prescription drugs your plan covers have been or will be ineffective, or have a negative effect on your health. Your doctor should also explain why the drug that isn’t on your drug list — the drug you’re requesting — would be more effective.

Here's how to request the review:

  • Mail us the completed external review form, along with a copy of our decision and the statement from your doctor. Select your plan type below for the address you'll need.

As soon as we get your request, we'll assign your case to an IRO. They'll inform you of their decision within 72 hours.

If they determine that we should cover the drug, we'll abide by their decision and cover the drug for the duration of the prescription, including refills.

Urgent External Review

If we denied your request and your circumstances are urgent, you may be able to request an urgent external review by an independent review organization, or IRO.

You may qualify for an urgent review if:

  • You're already going through a treatment with a drug that isn't listed on the pharmacy drug list.
  • Your health condition could be life threatening or you may lose the ability to regain full bodily function.
  • The timeframe of 72 hours would seriously jeopardize your life or health.

Select your plan type below to find out how to request an urgent review:

If you have any other questions, please call the number on the back of your Blue Cross ID card.

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Questions?

Privacy issues: To report a concern or if you think your protected health information has been compromised, please call 1-800-482-3787 or email privacy@bcbsm.com. Don't include any protected health information in your email. 

Other issues: For customer service, call the number on the back of your member ID card or 1-313-225-9000.