Prescription Drug Coverage Determination Forms

Who is this for?


If you're requesting a coverage determination for a Medicare Part D prescription drug, use this form.

Do you need a Medicare Part D prescription drug your plan doesn't cover? Want us to make an exception to how we cover a drug? You can ask for a coverage determination.

The best way to do this is to fill out our online coverage determination form.

What you'll need:

  • Your Blue Cross ID card.
  • Information about the drug you'd like us to cover for you.
  • The name and contact information of the doctor who prescribed the drug.

You can also fill out a paper coverage determination form. 

Request for Medicare Prescription Drug Coverage Determination (PDF)

Mail or fax your form to:

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Blue Cross Blue Shield of Michigan 
Clinical Pharmacy Help Desk – MC TC1308
P.O. Box 807
Southfield, MI 48037

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If you'd rather not fill out the form, you can write us a letter asking for coverage determination. Just use the address or fax number above.

You can also call the Customer Service number on the back of your Blue Cross ID card. Or you can ask us to call you.

Helpful tips:

  • Is someone else filling out this form for you? You'll need to include an appointment of representative form.
  • Need a quick decision about the drugs you're requesting? There's a section on the form where your doctor can explain why it's important for us to speed up the process.
  • Did we make a coverage determination you disagree with? You can file an appeal. We also call this asking for a redetermination.