What If My Prescription Isn’t Covered or Has New Restrictions?

We know it's scary to lose coverage for a prescription you count on. Or wonder how you'll afford the cost of a drug your plan doesn't cover.

That's why Blue Cross Blue Shield of Michigan has a transition policy for Medicare Part D prescription drugs. It gives you 108 days to work with us and your doctor to find a solution for your prescription.

When does the transition policy apply?

The transition policy is applicable when:

  • Your prescription isn't on your plan's drug list.
  • Your prescription was removed from your plan's drug list.
  • Your prescription requires approval or faces new restrictions, like prior authorization or step therapy.

You and your doctor will receive a letter if the status of your prescription changes.

How does the transition policy work?

In most cases, the transition policy applies only to Part D prescription drugs purchased at an in-network pharmacy. You can’t use it to fill a prescription for a drug that Medicare doesn’t cover. 

When it starts

When you enroll in a new plan, your transition period begins once your coverage starts. If you're already a plan member, your transition period begins at the beginning of the plan year. 

Steps you can take

You have options if your plan doesn't cover a Part D prescription drug or it has additional restrictions. During the transition period, you can:

  • Talk with your doctor about finding an alternative to the prescription you're taking that isn't on your plan's drug list. 
  • Go through any required approval process.
  • Ask us to make an exception for coverage of a prescription not on the drug list or for increasing a quantity limit. You'll need to submit a coverage determination form, and we usually make a decision within 72 hours. 

Interim coverage

During the transition period, in most cases, we'll cover at least one fill or refill of your prescription. It can be up to a month's supply from an in-network retail or mail-order pharmacy.

The transition policy provides additional help in specific circumstances, such as entering or leaving a long-term care facility or getting discharged from the hospital.

In these situations, the policy will:

  • Cover multiple prescription refills during the transition period, up to a month's supply at a time.
  • In some cases, cover a month's supply outside of the transition period.
Still need help?

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Related forms and documents

Request for Medicare Prescription Drug Coverage Determination (PDF)
Send us this completed form to request we make an exception for your drug.
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