How do I ask for my plan to cover a prescription drug or contraceptive?

Coverage Request Form

If you have a Blue Cross Blue Shield of Michigan PPO plan, or a Blue Care Network HMO plan, you can fill out the form below for a standard or expedited review. You should fill out this form if you need a drug or contraceptive that's not included on your drug list.

The items below will help us understand your needs. Please check all that apply (minimum of one option).*

You're going through a treatment that is not listed on the pharmacy drug list.
You need a medication or contraceptive that's not on the drug list and you believe it's medically necessary.
Your health condition could be life threatening or you may lose the ability to regain full bodily function.
This is a standard request.

It is required that at least one check box is selected.

Patient's first name* This field is required.

Patient's last name* This field is required.

Date of birth* This field is required.

Contract number* This field is required.

Email* This field is required. This is not a valid email.

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

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

Drug or contraceptive requested* This field is required.

Physician's first name* This field is required.

Physician's last name* This field is required.

Physician's phone number* This field is required. This is not a valid phone number.

Physician's fax number This is not a valid fax number.

Physician's city* This field is required.

This field is required.

If you have questions or need help with the appeal process, call the customer service number listed on the back of your Blue Cross ID card.