Coverage Request Form

* = required

If you have a Blue Cross Blue Shield of Michigan PPO plan, or a Blue Care Network HMO plan, you can fill out the form below for a standard or expedited review. You should fill out this form if you need a drug or contraceptive that's not included on your drug list.

The items below will help us understand your needs. Please check all that apply.
  • You're going through a treatment that is not listed on the pharmacy drug list.
  • You need a medication or contraceptive that's not on the drug list and you believe it's medically necessary.
  • Your health condition could be life threatening or you may lose the ability to regain full bodily function.
  • This is a standard request.

Type the above number:


If you have questions or need help with the appeal process, call the Customer Service number listed on the back of your Blue Cross ID card.