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.


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Why are you making this request?*
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Do you need an expedited decision?

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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.



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Complete this section only if you're completing this form for someone else.
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  • Page Last Updated Tue Jul 16 20:41:52 EDT 2024