Coverage Determination and
Redetermination

Blue Cross Medicare Advantage
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If your doctor or pharmacist tells you that we will not cover a prescription drug, you, as a Blue Cross Medicare AdvantageSM member, should contact us and ask for a coverage determination. Contact a Product Specialist to obtain information on how to file a grievance, appeal or exception with the plan sponsor.

Things to know about requesting an exception:

  • You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower payment.
  • If you request an exception, your doctor must provide a statement to support your request.
  • You must contact us if you would like to request a coverage determination (including an exception.)
  • You can request an appeal if we have issued an unfavorable coverage determination.

Learn more about coverage determination 

Medicare Prescription Drug Determination Forms

The Centers for Medicare & Medicaid Services (CMS) has a model Medicare prescription drug coverage determination form developed specifically for use by all Blue Cross Medicare Advantage prescribing doctors and enrollees.

Request for Medicare Prescription Drug Coverage Determination Form 
en Español

Formulary Exception

The formulary exception process is used to request coverage for a medication that's not on the drug formulary. All approvals for non-formulary medications will require a Tier 4 copay for brand name drugs or a Tier 2 copay for generic drugs. You can also request a tier exception for your non-preferred drug be covered at the preferred drug copay level. In other words, you can request that your non-preferred brand name drug (Tier 4) be covered at the preferred brand name (Tier 3) copay level; or your non-preferred generic drug (Tier 2) be covered at the preferred generic drug (Tier 1) copay level. This applies to five-tier benefit plans only.

Exception request form pdf icon

File a Grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Blue Cross Medicare Advantage prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.
Learn more 

Appeals/Redetermination

If you or your doctor do not agree with the outcome of the initial coverage determination, you or your doctor must appeal the decision by having your doctor request a redetermination. Your appeal includes formulary, coverage rule or tiering exceptions.

Request for Redetermination of Medicare Prescription Drug Denial Form 
en Español

How do I obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan?

To obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan, contact Blue Cross Medicare Advantage Customer Service Toll Free at 1-877-774-8592.

We are open 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY/TDD: 711.