Medicare Part D and Medicaid Drugs

When you join our plan, if you are taking any prescription or over-the-counter drugs that Blue Cross Community MMAI (Medicare-Medicaid Plan)SM does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for Blue Cross Community MMAI to cover your drug, if medically necessary.

Coverage Determination and Appeals

If your doctor or pharmacist tells you that a prescription drug is not covered, you may ask the plan for an exception or coverage determination. You can also ask for help to find a different drug. Here are examples of when you may want to ask the plan for a coverage determination or exception:

  • If there is a required limit on the quantity (or dose) of a drug and you disagree with the limit.
  • If prior authorization is required for the drug.
  • You have the right to ask us for an “exception” if you believe you need a drug that is not on our drug list.
  • If you ask for an exception, your doctor must send the plan a statement to support your request.
  • You can appeal an unfavorable coverage determination.

A coverage determination request can be submitted either as standard (72-hour turn-around time) or expedited (24-hour turn-around time). To learn more about coverage determination, see Chapter 9 of the Member Handbook on the Forms and Documents page.

Below are the steps to follow if you decide to ask for a coverage determination.

Step 1: Initial Coverage Determination Request

There are several types of coverage determinations.

Prescription Drug Coverage Determination

To ask us for a pharmacy prior authorization, step therapy exception or quantity limit exception, you or someone on your behalf can fill out and fax the form below to 1-800-693-6703.

Prior Authorization Form

Online Coverage Determination Request Form

Prescription Drug Formulary Exception

The formulary exception process is used to ask for coverage of a medication that’s not on the drug list.

Prescription Drug Formulary Exception Physician Form

You, your doctor or your representative can also submit a coverage determination or exception request using MyPrime1.

For assistance, Contact Us.

Step 2: Appeals to Initial Coverage Determination and Asking for a Redetermination

Prescription Drug Appeals and Redeterminations

Asking for a Redetermination or Appeal

An initial coverage determination decision can be appealed. To start your appeal, you (or your representative or your prescriber) must contact us. Include any information that may be helpful with your redetermination request.

You must ask for your appeal within 60 calendar days after the date of the denial notice. We can give you more time if you have a good reason for missing the deadline.

Request for Redetermination of Medicare Prescription Drug Denial

You, your prescriber or your appointed representative may ask for an expedited (fast) or standard appeal. For an expedited (fast) or standard appeal, you, your prescriber, or your appointed representative may contact us by phone, fax or mail:

1-877-723-7702 (TTY 711).

We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 a.m. – 8:00 p.m. Central time.

Fax Number:

Mailing Address:
Blue Cross Community MMAI
c/o Pharmacy Benefit Manager
2900 Ames Crossing Road
Eagan, MN 55121

Appointment of Representative

You, your doctor, or your representative may request an appeal. You can name a relative, friend, attorney, doctor or someone else to be your representative.

Appointment of Representative

You can Contact Us to learn how to appoint a representative.

File a Grievance

A grievance is a complaint about any matter besides a service that has been denied, reduced or ended. It is different from a coverage determination because it usually does not involve coverage or payment for prescription drugs.

If you have a grievance, we encourage you to Contact Us. You may also contact Medicare by using the online form at

Information on how to obtain aggregate number of grievances, appeals, and exceptions can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY 711)

Mailing Address:
Blue Cross Community MMAI
Appeals and Grievances
P.O. Box 660717    
Dallas, Tx, 75266-0717

Fax: 1-866-643-7069

General Information Questions

Additional information about your benefits can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY 711)

Mailing Address:
Blue Cross Community MMAI
Medicare Part D General Information
P. O. Box 3836
Scranton, PA 18505

Fax: 1-855-674-9193 is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, a separate company providing pharmacy benefit management services for your plan.