What do I need to know about coverage decisions?

Who is this for?

Learn more about coverage decisions.

When you want to ask your plan to cover or share the cost of a medical service or drug, this explains how to ask for a coverage decision.

Did you know coverage decisions are a regular part of getting medical care? They're also a regular part of getting a prescription, except we call them coverage determinations.

That's because your plan makes a coverage decision every time it decides what's covered and how much it pays.

Sometimes, you or doctor will need to check with your plan to see if something is covered before you get it. That's asking us to make a coverage decision or determination.

How it works

Carl has diabetes. To help Carl stay healthy, his doctor recommends diabetes self-management training. Carl looks in his Evidence of Coverage for his Medicare Advantage plan to see if it's covered. It says the training is covered under "certain conditions." So his doctor calls his plan, which agrees to pay for the training. Carl's plan made a coverage decision.

Juanita takes a prescription for her arthritis. Her plan has a quantity limit on the drug, which means she can only get so many pills within a certain amount of time. Now her doctor feels she would benefit by increasing the dosage. So he contacts Juanita’s insurance company and asks them to change the quantity limit. That’s asking for a coverage determination.

If you have a Medicare Advantage or Prescription BlueSM PDP plan, you can learn more about coverage decisions in your plan's Evidence of Coverage.

Who can ask for a coverage decision?

In most cases your doctor will contact us. You or someone other than your doctor acting on your behalf—a representative—can also ask for a coverage decision.

How long does a coverage decision take?

It depends on what you’re asking us about.

  • If your coverage decision is related to a medical service you haven't received yet, we’ll reply within 14 days.
  • If your coverage decision is related to prescription drugs you haven't received yet, we’ll reply within 72 hours.

What if I can’t wait that long?

We can give you what’s called a fast decision if:

  • Waiting could cause serious harm to your health or hurt your ability to function.
  • You’re asking for a coverage decision about medical care or a prescription drug you haven’t received yet.

In these cases, we’ll reply within 72 hours if it’s related to a medical service, and 24 hours if it’s related to a prescription drug.

It’s best to have your doctor or pharmacist request a fast coverage decision.

How do I ask for a coverage decision?

If your doctor doesn’t do it for you, the best way to start is by calling the customer service number on the back of your Blues ID card. You can also write us, send a fax or fill out a form. You’ll find all the information you need when you choose your plan below.

If a representative will be doing it for you, make sure you fill out and send us an Appointment of Representative form. We won’t be able to make our decision without it.

I want to ask my plan about covering a medical service

I want to ask my plan to cover a prescription drug or change how a drug is covered

Coverage decisions for prescription drugs are also called coverage determinations. You can request coverage determination when:

  • You believe you need a drug covered by Medicare Part D that's not on your plan's drug list.
  • You want a tier exception. That's asking us to lower your copay for a Tier 2 or Tier 4 drug.
  • You want an exception to the step therapy, prior authorization, quantity limit or other requirements we have for a drug.

You can find information about tiers, step therapy, prior authorization and more by looking in your plan's drug list.

If you want to talk to us about a coverage determination, start by calling the customer service number on the back of your Blues ID card. Or fill out our online callback form and we’ll call when it’s convenient for you.

If you’d rather write us a letter, send a fax or submit a form, the information you need is below.

What if you say no to my request?

You can file an appeal.