Medicare Prescription Drug Coverage Determination Form

If you need a drug that's not currently covered by your Blue Cross Blue Shield of Michigan Medicare plan, you can request a coverage determination from us with this form.

Note: Fields with an asterisk are required.

Enrollee ID, found on your Blue Cross ID card* Enrollee ID, found on your Blue Cross ID card is required.

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

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

Street address* Street address is required.

City* City is required.

State* Select a state is required.

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

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

Prescribing doctor's name* Prescribing doctor's name is required.

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

Name of prescription drug, its strength and quantity per month, if known* Name of perscription drug, it's strength and quantity per month, if known is required.

Why are you making this request?*

I need a drug that isn't covered by my plan.

I've been using a drug that was previously covered by my plan but is being removed or was removed this year.

I'm requesting a prior authorization for my prescription.

I'm requesting an exception to the requirement that I try another drug before I get the drug prescribed.

I'm requesting an exception to my plan's quantity limit.

My plan charges a higher copay for the drug prescribed than it charges for another drug that treats my condition. I want the lower copayment.

I've been using a drug that had a lower copay but now has a higher one.

My plan charged me a higher copay for a drug than it should have.

I want to be reimbursed for a covered drug that I paid for out of pocket.

Why are you making this request is required.

Do you need an expedited decision?

Yes, I need an expedited decision.

This field is required.

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm you, you can ask for an expedited decision.

If your prescriber indicates that waiting 72 hours could seriously harm your health, we’ll give you a decision within 24 hours.

If you don’t get your prescriber’s support for an expedited request, we’ll decide if your case requires a fast decision. You can’t request an expedited decision if you’re asking us to pay you back for a drug you already received.

Your full name* Your full name is required.

You have the right to request that we send a hard copy of this form to you in the mail. By checking this box, you agree to receive and submit this form electronically.*

This field is required.

Complete this section only if you're completing this form for someone else.

Your full name

Your relationship to the enrollee

Your phone number, if different from the enrollee's

reCAPTCHA is required.

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Page Last Updated Fri Dec 27 13:35:45 EST 2024