Blues give instructions for Medicare Part D coverage determination process

For our Medicare Advantage health care providers, we’ve created an instruction guide for the Blue Cross coverage determination process for Medicare Part D. The Blue Cross Blue Shield of Michigan Medicare Advantage Part D drug coverage guidelines are available in Provider Secured Services on bcbsm.com and includes the following resources:

• An explanation of when and how to request a coverage determination
• The timeline for receiving a decision
• Links to our formularies

Our Part D formularies and drug-use guidelines encourage you to choose options that are low-cost as well as safe and effective.

In some cases, you may need to use a nonformulary drug or have the restrictions to the drug removed (e.g., quantity limit, prior authorization or step therapy requirements). In those situations, the Centers for Medicare & Medicaid Services requires that Medicare Part D plans provide patients and prescribers with a process to bypass these restrictions when medically necessary.

That process is also included in the instruction guide. It’s located in Provider Secured Services:

• Go to bcbsm.com.
• Log in to Provider Secured Services.
• In the left-hand navigation, click on BCBSM Publications and Resources.
• Click on Medicare Advantage Resources.
• Under What's New, click on Medicare Advantage provider coverage determination job aid.

If you have any questions about coverage determination, please call our Clinical Pharmacy Help Desk at 1-800-437-3803 or your provider consultant.