Requesting an appeal?

If you have a received a decision from Medicare Plus BlueSM PPO or Prescription BlueSM PDP that indicates we will not pay for a drug or service you believe you are entitled to, or you believe we have not paid for the drug or service as you anticipated, you may ask us to reconsider or appeal our coverage decision.

The first step is to call Member Services at the number printed on the back of your ID card.

If you are unable to file your own appeal, you may appoint someone, such as your spouse, child, neighbor or friend, to act on your behalf.

Our representatives may be able to:

If, after speaking with a Member Services representative, you still wish to file an appeal for a service or item, you may advise the representative verbally, and he or she will document your request and forward it to the Grievance and Appeals Department.

If, after speaking with a Member Services representative, you still wish to file an appeal for a drug, you may advise the representative or use the Coverage Determination, Appeal or Grievance form.

If you do not want to call, you can complete these steps to initiate your appeal:

  1. Describe what you would like to appeal and, if possible, include a copy of the denial that you received.
  2. Include your name, member ID, a daytime telephone number and signature.
  3. Send the information to us:
For drug-related appeals: For service or item appeals:
By mail:
Blue Cross Blue Shield of Michigan
Clinical Pharmacy Help Desk — C303
P.O. Box 807
Southfield, MI 48037
By mail:
Blue Cross Blue Shield of Michigan
P.O. Box 2627
Detroit, MI 48231-2627
By fax:
1-866-601-4428
By fax:
1-877-348-2251

We will generally respond to you according to the following standard timelines:

Certain situations allow you to request a "fast decision" about whether or not Medicare Plus Blue PPO or Prescription Blue PDP will pay for the service. You can only ask for a "fast decision" when:

The information above is a brief summary. Refer to your Evidence of Coverage for complete information about your rights, benefits and responsibilities (Chapter 8 for Medicare Plus Blue PPO members; Chapter 6 for Prescription Blue PDP members).

For expedited requests ("fast decisions") only, you may call 1-877-241-2583, 8 a.m to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. You may also fax to 1-877-348-2251.

H9572 S5584_W_Apr14BCBSMAdvWeb Pending CMS Approval

Important information about these plans

Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare-allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit http://www.bcbsm.com/medicare/find-a-doctor/.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium. You may enroll in only one Part D plan at a time.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,400 Michigan retail pharmacies, representing approximately 98 percent of all Michigan pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances; for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-241-2583, 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X521, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and or copayments/coinsurance may change on Jan. 1 of each year.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCBSM does not control Medicare's website and is not responsible for its content. You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-888-563-3307. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14.

LegacySM Medigap

Legacy Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. Legacy Medigap is a Medigap health insurance policy administered by Blue Cross Blue Shield of Michigan. Neither Blue Cross Blue Shield of Michigan nor agents authorized to sell Blue Cross Blue Shield of Michigan policies are connected with Medicare.