Coverage Determination and
Redetermination


Print

If your doctor or pharmacist tells you that we will not cover a prescription drug, you, as a Blue MedicareRxSM member, should contact us and ask for a coverage determination. Contact Customer Service to obtain an aggregate number of grievances, appeals, and exceptions filed with the plan sponsor.

Things to know about requesting an exception:

  • You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower payment.
  • If you request an exception, your doctor must provide a statement to support your request.
  • You must contact us if you would like to request a coverage determination (including an exception).
  • You can request an appeal if we have issued an unfavorable coverage determination.

Learn more about coverage determination 

Medicare Prescription Drug Determination Forms

The Centers for Medicare & Medicaid Services (CMS) have a model Medicare prescription drug coverage determination form developed specifically for use by all Part D prescribing physicians and enrollees.

Request for Medicare Prescription Drug Coverage Determination Form  en Español

Formulary Exception

A formulary exception is used to request coverage for a medication not on the drug formulary (not covered) or to request coverage of a drug on drug level 3 to be covered at drug level 2 (applies to four-tier benefit plans only).

Exception request form 

File a Grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process).
Learn more 

Appeals/Redetermination

If you or your doctor do not agree with the outcome of the initial coverage determination, you or your doctor must appeal the decision by having your doctor request a re-determination. Your appeal includes formulary exceptions, coverage rule exception, or tiering exception.
Appeal Instructions 

Request for Redetermination of Medicare Prescription Drug Denial Form  en Español

Need Assistance?


Blue MedicareRx

Call 1-877-213-1821


This information is available for free in other languages. Please contact our Customer Service number at 1-877-213-1821 for additional information. (TTY/TDD users should call 711). Hours are 8 a.m. - 8 p.m., local time, 7 days a week. From February 15th through October 14th alternate technologies (for example, voicemail) will be used on the weekends and holidays. Customer Service also has free language interpreter services available for non-English speakers. en Español

Contact us: Blue MedicareRx
                      P.O. Box 3897
                      Scranton, PA 18505-9947