Why won’t you cover the drug my doctor prescribed?

Who is this for?

Michigan Health Insurance – Customer Service – Pharmacy

If you're a Blue Care Network member, this information will help you know what you can do if we decline to cover your prescription drug.

We want our members to get the safest and most cost-effective medication. That means sometimes we may not cover a drug your doctor has prescribed. It might be because it's a new drug that doesn't yet have a proven safety record. Or, there might be a less expensive drug that works just as well.

You can find more information about drugs we don't cover in "How can I understand my Blue Care Network prescription drug benefits?"

How to appeal a pharmacy denial

A drug that's not in our formulary, sometimes called a drug list, may require prior authorization. Or, it might not be a covered benefit under your drug plan. Blue Care Network reviews all physician and member requests to determine if the drug is medically necessary and if there are equally effective alternative drugs on the formulary. We will notify both you and your doctor in writing if the request is denied. We will include information on how to appeal our decision, and either you or your doctor can initiate the appeal process. Please call Customer Service if you have questions regarding a drug authorization, a drug claim or your eligibility.

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