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:
- Prior authorization
- Coverage decision about payment
- Exception
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 authorizations
You 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 request
For 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:
- The diagnosis or reason(s) you are being treated with the drug
- Lab test information (for example, LDL level for cholesterol treatment or the hemoglobin A1C level for diabetes treatment)
or
- Your doctor's specialty or whether you have been evaluated by a specialist
- What other treatment(s) has been attempted, whether it was effective, or whether you experienced side effects from the treatment(s)
or
- What dose is required and how long your expected treatment is
- Whether a generic drug alternative is medically appropriate for you
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.
Fax: (888) 697-8122
Mail: Blue Shield of California
PO Box 2080
Oakland, CA 94604-9716
Exceptions
You, 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:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, we limit the quantity on certain drugs we cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is in the Non-Preferred Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Drug tier, so long as there is a formulary drug that treats your condition on this tier. This would lower the amount you pay for your medications.
How do I request an exception?
Submit an exception by fax or mail
If 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 payment
As 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 forms
Start a coverage determination request online
You 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 request
Medicare Part D coverage request form for enrollees, English (PDF, 194 KB)
Medicare Part D coverage request form for enrollees, Español (PDF, 167 KB)
Submit a direct member reimbursement form by mail
The 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)
DMR form for Medicare members, Español (PDF, 144 KB)
Mail the completed DMR form to:
Blue Shield of California
P.O. Box 52066
Phoenix, AZ 85072-2066
If you need to authorize a representative, learn how on our Appointment of Representative page.
Provider forms
Use this Prior Authorization Form (PDF, 141 KB) to submit by mail or fax.
To submit a formulary or tiering exception, use the forms below:
Non-Formulary Exception and Quantity Limit Exception (PDF, 86 KB)
Tier Exception (PDF, 109 KB)
To submit a request for review for Part D Drugs Unrelated to Hospice, use the form below:
Hospice Form (PDF, 123 KB)
Phone: (800) 535-9481 (TTY: 711), Monday through Friday from 8 a.m. – 6 p.m. PST
Fax: (888) 697-8122
Mail: Blue Shield of California
PO Box 2080
Oakland, CA 94604-9716
Online: Log in to Provider Connection to submit an online Prior Authorization request.
If you need to authorize a representative, learn how to do this on our Appointment of Representative page.