Prescription Drug Coverage Determination Forms

Who is this for?


If you're requesting a coverage determination for a Medicare Part D prescription drug, use these forms.

Do you need a Medicare Part D prescription drug your plan doesn't cover? Want us to make an exception to how we cover a drug? You can ask for a coverage determination.

The best way to do this is to call the customer service number on the back of your Blues ID card. Or you can ask us to call you.

You can also fill out a coverage determination form. Choose your plan below to find the right one.

What you'll need:

  • Your Blues ID card.
  • Information about the drug you'd like us to cover for you.
  • The name and contact information of the doctor who prescribed the drug.
  • You may also need an explanation from your doctor and supporting documents.

Helpful tips:

  • Is someone else filling out this form for you? You'll need to include an appointment of representative form.
  • Need a quick decision about the drugs you're requesting? There's a section on the form where your doctor can explain why it's important for us to speed up the process.
  • Did we make a coverage determination you disagree with? You can file an appeal. We also call this asking for a redetermination.