How do I ask for my plan to cover a prescription drug or contraceptive?

Coverage Request Form

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 (minimum of one option).*

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 request is urgent, such as when your condition may be life threatening or may result in loss of ability to regain full bodily function.
This is a standard request.

It is required that at least one check box is selected.

Patient's first name* Patient's first name is required.

Patient's last name* Patient's last name is required.

Date of birth* Date of birth is required.

Contract number* Contract number is required.

Email* Email is required. This is not a valid email.

ZIP code* ZIP code is required. This is not a valid ZIP code.

Phone* Phone is required. This is not a valid phone number.

Drug or contraceptive requested* Drug or contraceptive requested is required.

Physician's first name* Physician's first name is required.

Physician's last name* Physician's last name is required.

Physician's phone number* Physician's phone number is required. This is not a valid phone number.

Physician's fax number This is not a valid fax number.

Physician's city* Physician's city is required.

Recaptcha is required.

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.