Coverage Request Form

* = required

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.

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.

Patient's First Name*

Patient's Last Name*

Date of Birth*

Contract Number*

Email*

ZIP code*

Phone*

Drug or Contraceptive Requested*

Physician's First Name*

Physician's Last Name*

Physician's Phone Number*

Physician's Fax Number

Physician's City*

Type the above number:

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.

Coverage Request Form

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