Prescription Drug Coverage Determination Form

If you're looking for us to cover a drug that's not currently on our list, you should request a coverage determination.

*Subscriber ID, also known as enrollee ID, found on the back of your Blue Cross ID card

*Subscriber's first name

*Subscriber's last name

*Permanent street address

*Prescribing doctor's name

*Prescribing doctor's phone number

*Name of prescription drug requested and its strength and quantity per month, if known

Why are you making this request? I need a drug that isn't covered by my plan. I've been using a drug that was previously covered by my plan but is being removed or was removed this year. I'm requesting a prior authorization for my prescription. I'm requesting an exception to the requirement that I try another drug before I get the drug prescribed. I'm requesting an exception to my plan's quantity limit. My plan charges a higher copay for the drug prescribed than it charges for another drug that treats my condition. I want the lower copayment. I've been using a drug that had a lower copay but now has a higher one. My plan charged me a higher copay for a drug than it should have. I want to be reimbursed for a covered drug that I paid for out of pocket.

Do you need an expedited decision?

Yes, I need an expedited decision.

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm you, you can ask for an expedited decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we’ll give you a decision within 24 hours. If you don’t get your prescriber’s support for an expedited request, we’ll decide if your case requires a fast decision. You can’t request an expedited decision if you’re asking us to pay you back for a drug you already received.

Acknowledgment with legal language goes here

Please complete this section only if you are filling out this form for someone else and you aren't the prescribing doctor.

Your full name, if different from the subscriber's

Your relationship to the subscriber

Your phone number to contact, if different from the subscriber's

Type the above number: