Coverage Determination

What is a coverage determination?

If a pharmacist says that your plan doesn’t cover a prescription drug and you believe the drug should be covered, you can request us to cover it. The process by which we decide to approve or deny your request is called a coverage determination.

Reasons to request a coverage determination include:

  • If you cannot get a drug that you believe you need
  • If we won’t pay for a drug you think we do cover
  • If we won’t pay for a drug because it isn’t on our drug list
  • If you disagree with the cost of a drug
  • If we notify you that coverage for a drug you take will be reduced or stopped
  • If you disagree with a limit on the quantity (or dose) of a drug
  • If we require you to try another drug before we will pay for another drug
  • If you want to request drug coverage at an out-of-network pharmacy
  • You want to request reimbursement for a drug you’ve already received
  • You want to request an exception to a plan rule (for instance, tiering)

Who may ask for a Coverage Determination?

Your pharmacist cannot make a coverage determination. You, your doctor, your lawyer, or your appointed representative can request a coverage determination by submitting the forms explained below. You are not required to hire a lawyer or appoint a representative.

How to appoint a representative

If you wish to appoint a relative, friend, advocate, doctor, or anyone else to act as your legal representative, you and that person will need to complete and sign an Appointment of Representative form (PDF). You must complete this form and file it with each request for a coverage determination.

How to submit a request

You must submit each request no later than three (3) years from the date of service. To ensure we have all the necessary information, we prefer that your doctor submit your request(s) for a coverage determination.

To have your doctor submit a request, download our Physician Coverage Determination form and ask your doctor to complete and submit it via mail or fax, as directed on the form.

If you or your attorney or representative is filing a request, download, complete, and submit a Beneficiary Coverage Determination Request Form available under documents. This form can be submitted online by completing our Electronic Beneficiary Coverage Determination form. This form can also be mailed or faxed, as directed on the form.

To make a request by phone, Contact Us, 24 hours a day, 7 days a week.

Standard and Expedited Coverage Determination Requests

Standard Coverage Determination Request

For a standard coverage determination, including requests for payment for a drug you’ve already received, we will make a decision within 72 hours of receiving your request.

Expedited Coverage Determination Request

You can request an expedited (fast) coverage determination if you or your doctor believes that waiting 72 hours could seriously harm your health or your ability to function. If we grant your request, we will make a decision within 24 hours. If your doctor asks for the fast coverage determination, or supports your own request, we will automatically make a decision within 24 hours.

An expedited coverage determination applies only to requests for drugs that you have not received yet. If your request does not include a written statement from a doctor, we will decide if your health requires an expedited determination. If we deny your request, we can still make a fast decision if you provide a doctor’s supporting statement. You or your physician may Contact Us regarding the status of your coverage determination.

What if your request is denied?

If we deny your request entirely or in part, we will send you a written explanation. If a coverage determination does not give you all you requested, you have the right to appeal the decision by requesting a redetermination.

Please contact Blue MedicareRx (PDP), 24 hours a day, 7 days a week for a printed version of our pharmacy directory or additional information. Contact Us.

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