How to request a review for your coverage of a prescription drug
Who is this for?
This information can help you if you need to request a review for your coverage of a drug that isn't on your drug list or covered by your plan.
Sometimes, your doctor might prescribe a drug that isn't on your drug list or covered by your plan. If so, work with your doctor to see if they can prescribe a similar drug that's on the list.
If after talking with your doctor, you both agree that this is the right medication for you, you can request our review.
In most cases, we'll have 72 hours to make our decision and let you or your doctor know. If the drug is needed urgently or is part of your current treatment, typically, we'll make a decision within 24 hours.
If you have a PPO or EPO plan with Blue Cross Blue Shield of Michigan, you can use this coverage request form when:
- You need a medication that's not on your drug list and you believe it's medically necessary.
- You're going through a treatment that's not on your drug list.
- You need an urgent review for your drug coverage because your health condition could be life threatening.
If you have a Multi-State Plan, you should also use this request form.
If you get a prescription for a drug that isn't on your drug list, your doctor can contact the Blue Care Network pharmacy help desk to request approval. Or you can call Customer Service using the number on the back of your Blue Cross ID card.
We can help you request prior authorization for your medication. Just fill out the Blue Care Network HMO Drug Prior Authorization Callback form. We'll call you within one business day and help guide you through your prior authorization request.
Do you have an employer-sponsored plan?
There might be some drugs on your drug list that aren't covered, because some categories might be excluded by your plan. Log in to your account at bcbsm.com and go to My Coverage to learn about your specific coverage.
How do I file an appeal?
If we deny your request, you can file an appeal. The process for filing an appeal differs based on how you bought your plan and what plan you have. Read more about filing an appeal in our important information section.