The formulary, or list of covered drugs, for Medicare Plus Blue PPOSM and Prescription Blue PDPSM, includes medications selected to meet members' needs. However, if you and your physician feel you need a drug that is not included on the Medicare Plus Blue PPOSM and Prescription Blue PDPSM formulary, but it is a covered Medicare Part D drug, you may ask us for a coverage determination or an exception.
Request for Medicare Prescription Drug Coverage Determination form (PDF)
Need help with the Coverage Determination form?Instructions on how to complete a Request for Medicare Prescription Drug Coverage Determination form
Please note that you may not ask for a coverage determination or exception for medications not covered under Medicare Part D such as:
- Non-prescription drugs (also called over-the-counter drugs)
- Fertility drugs
- Drugs for the relief of cough or cold symptoms
- Drugs used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
- Drugs used for treatment of anorexia, weight loss or weight gain
- Outpatient drugs for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer
- Barbiturates, except when used to treat epilepsy, cancer, or a chronic mental health disorder
- Drugs that are covered under Medicare Part A or Medicare Part B
Drug coverage determinations and exceptions are further explained in your Evidence of Coverage and below (reference Chapter 5 for Medicare Plus Blue PPOSM members; Chapter 3 for Prescription Blue PDPSM members).
What are coverage determinations and tier requests?
A coverage determination is a decision about whether or not to provide or pay for Medicare Part D drugs, and what your share of the cost will be. Coverage determinations include exception requests. You have the right to ask us for an exception if you believe you need a drug that is not on our formulary, believe you should get a drug at a lower copayment, or are requesting an exception to the step therapy or prior authorization requirement for a drug.
You may ask for a tier exception for Tier 2 and 4 drugs only. This means you can ask that your copay for your Tier 2 drug be reduced to the copay of a Tier 1 drug and Tier 4 drug be reduced to the copay of a Tier 3 drug when your doctor can provide clinical information that indicates you cannot take any other formulary drug option for your condition. You cannot ask for a tiering exception for a Tier 5 (Specialty) drug. Additionally, you cannot obtain a brand-name drug at the copayment that applies to generic drugs.
If you request a tier exception your doctor must provide a statement to support your request.
You can call us to request a coverage determination by telephone or you may submit the Coverage Determination Form by fax or mail.
Fast, or expedited, vs. standard coverage determination for prescription drugs
A decision about whether we will cover a Medicare Part D prescription drug can be a "standard" coverage determination that is made within the standard time frame (typically within 72 hours; see below), or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours). For those decisions that require documentation from the prescribing physician the time frame does not start until that documentation is submitted. If no documentation is submitted, the request will not be approved.
Fast, or expedited, coverage determination
A fast decision is sometimes called an "expedited coverage determination." You, your prescribing physician or authorized representative can ask for a fast decision. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast review. (Fast decisions apply only to requests for Medicare Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Medicare Part D drug that you already received.)
You or your appointed representative can ask us to give you a fast decision (rather than a standard decision) by calling the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM identification card. Your doctor can ask us to give a fast decision by calling the Pharmacy Services Clinical Help Desk at 1-800-437-3803, Option 1, from 8 a.m. to 8 p.m. Monday through Friday. TTY users call 711.
Standard Coverage Determination
To ask for a standard decision, you or your appointed representative can contact us by calling the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM identification card. Your doctor can ask us to give a fast decision by calling the Pharmacy Services Clinical Help Desk at 1-800-437-3803, Option 1, from 8 a.m. to 8 p.m. Monday through Thursday, Friday from 8 a.m. to 6 p.m. TTY users call 1-800-649-3777.
Call the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM ID card. For expedited requests outside of regular business hours, call the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM ID card and follow the instructions provided.
Blue Cross Blue Shield of Michigan
Pharmacy Help Desk — C303
P.O. Box 807
Southfield, MI 48037