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Why won’t you cover the drug my doctor prescribed?

Who is this for?

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If you're a Blue Care Network member, this information will help you know what you can do if we decline to cover your prescription drug.

We want our members to get the safest and most cost-effective medication. That means sometimes we may not cover a drug your doctor has prescribed. Maybe it's a new drug that doesn't yet have a proven safety record. Or there might be a less expensive drug that works just as well.

You can find more information about drugs we don't cover in "How can I understand my Blue Care Network prescription drug benefits?"

How to appeal a pharmacy denial

A drug that's not in our formulary, that requires prior authorization or is not covered under your drug plan may not be a covered benefit. Blue Care Network reviews all physician and member requests to determine if the drug is medically necessary and that there aren't equally effective alternative drugs on the formulary. We will notify both you and your doctor in writing if the request is denied. We will include information on how to appeal our decision, and either you or your doctor can initiate the appeal process. Please call Customer Service if you have questions regarding a drug authorization, a drug claim or your eligibility.

 

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