ONLINE FORM
Prescription Drug Coverage Determination Online Form
If you want Blue Cross to make an exception for a drug, you can ask us for a coverage determination. You'll need information about the drug you want covered and the name and contact information of the doctor who prescribed the drug.
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Prescription Drug Coverage Determination Paper Form
You can also fill out and mail this form to ask for an exception for a prescription drug.
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Medicare Plus Blue PPO and Prescription Blue PDP Request for Redetermination Form
If you have a Medicare Plus Blue PPO or Prescription Blue PDP plan and want to appeal a decision we've already made about a prescription drug, you can ask us to review it with this form. If possible, include the letter you received from us that you'd like to appeal.
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BCN Advantage HMO and HMO-POS Request for Redetermination Form
If you have a BCN Advantage HMO or HMO-POS plan and want to appeal a decision we've already made about a prescription drug, you can ask us to review it with this form. If possible, include the letter you received from us that you'd like to appeal.