Coverage Request Form
If you have a Blue Cross Blue Shield of Michigan PPO or EPO plan, you can fill out the form below for a standard or expedited review. You should fill out this form if you need a drug that's not included on your drug list.
The items below will help us understand your needs. Please check all that apply.
If you have questions or need help with the appeal process, call the Customer Service number listed on the back of your Blue Cross ID card.