You may request an exception to your prescription medication coverage for drugs that are not included on your prescription drug list. Please note the following restrictions; a formulary exception request is for non-covered self-administered drugs only. A formulary exception request is different from a prior authorization request which is required for certain covered drugs. Show To make a request for an exception to your prescription medication coverage, you can complete one of the following options: We will contact your prescribing physician for a statement to support the request for a formulary exception. Generally we make our decision within 7 business days of receiving your prescribing physician's supporting statement. We will send a letter to you and your prescribing physician once a decision has been made. If you are in Medicare Part D plans BlueRx or Blue Advantage, please call the number on the back of your member identification card for assistance. A coverage determination, also called a coverage decision, is a decision we make about your benefits and coverage or about the amount we will pay for your medications. An initial coverage decision about your Part D drugs is called a “coverage determination.” There are several different types of coverage determinations you can request:
Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision. Prior authorizationsYou may need to ask us to cover a drug on your plan's formulary (list of covered drugs) that needs prior authorization, because you meet the coverage rules. How do I request a prior authorization?To request a prior authorization for a drug, you, your healthcare provider, or appointed representative need to contact Blue Shield of California and provide clinical information. If the necessary information is not submitted, or the information does not meet the prior authorization criteria, the drug may not be covered. Learn more about what clinical information may be required below. Clinical information for your prior authorization requestFor a prior authorization request to be considered for approval, a doctor must provide clinical information which may include, but is not limited to, the following:
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Use the coverage determination form if you are submitting by fax or mail. Call the Customer Care number located on your Blue Shield member ID card. You may be asked to provide your doctor’s office phone or fax number. ExceptionsYou, your doctor, other prescriber, or your appointed representative can ask us to make an exception to our coverage rules. You can request several types of exceptions:
How do I request an exception?Submit an exception by fax or mailIf you request a formulary or tiering exception, your doctor must provide a statement supporting your request. Find the forms you need below. You, your doctor, or other prescriber may also contact us directly to request an exception, or check on the status of a request by calling Customer Care at the number on your member ID card. Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Preferred Generic Drugs tier or the Specialty Tier Drugs. Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects. Coverage determination about paymentAs an eligible Medicare Part D member, any time you pay out-of-pocket for a prescription that your pharmacy benefit plan covers, you can submit a request for reimbursement. This process is called direct member reimbursement or DMR. You will find the DMR form in the Member forms section. Member formsStart a coverage determination request onlineYou may start the process to obtain prior authorization or an exception. Your doctor or an authorized member of their staff may then be required to provide supporting medical documentation. Your doctor can also contact Blue Shield's Pharmacy Services to request a prior authorization on your behalf. Use the coverage determination form if you are submitting by fax or mail. Coverage determination requestMedicare Part D coverage request form for enrollees, English (PDF, 194 KB) Submit a direct member reimbursement form by mailThe reimbursement form must be received within one year from the date you paid for the service. Submission of the form is not a guarantee of payment. If you need help completing the DMR form, please contact your pharmacist or call Customer Care at the number on your Blue Shield member ID card. DMR form for Medicare members, English (PDF, 233 KB) Mail the completed DMR form to: If you need to authorize a representative, learn how to do this on our Appointment of Representative page. |