What is coverage determination?

Coverage determination, also called "coverage decision," is a decision that Blue Shield of California Promise Health Plan makes about benefits and coverage or about the amount we will pay for your drugs. Your benefits as a member include coverage for many prescription drugs.

To be covered, the drug must be used for a medically accepted indication. (A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration (FDA) or supported by certain reference books.) An initial coverage decision about your Part D drugs is called "coverage determination."

Step-by-step coverage decision request process

Step 1 – Ask your plan to make a coverage decision for the prescription drugs you are requesting

You, your doctor, or your appointed representative may do this by contacting Member Services via phone, fax, or mail.

 Phone:(800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week from October 1 through March 31, and Monday through Friday from April 1 through September 30.
 Fax: (866) 712-2731
 Blue Shield of California Promise Health Plan
Member Services (Coverage Decisions)
601 Potrero Grande Drive
Monterey Park, CA 91755

We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form:
Members - Drug Coverage Determination request form (PDF, 119 KB)
Providers - Drug Prior Authorization request form (PDF, 138 KB)

Check what drugs require prior authorization by using the drug search tool or by referring to this list:
Drug prior authorization requirements (PDF, 3.6 MB)

If your health requires a quick response, you must ask us to make a "fast coverage decision." You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

To get a fast coverage decision, you must meet two requirements:

  1. You are asking us to cover a drug you have not yet received
  2. Only if using the standard deadlines could cause serious harm to your health or hurt your ability to function

Please call or fax using the contact numbers above when you need a fast decision (expedited request).

Note: If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.

If you are requesting an exception, you must provide the "supporting statement." Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. Your doctor or other prescriber can fax or mail the statement to us. Additionally, they can tell us by phone, then follow up by faxing or mailing a written statement if necessary.

Step 2 – We consider your request and give you a coverage decision

Standard coverage decision

For a standard coverage decision, we must give you our answer within 72 hours. In most cases, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.

If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, where it will be reviewed by an Independent Review Entity.

If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.

Fast coverage decision

If we are using the fast deadlines, we must give you our answer within 24 hours. Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.

If we answer yes to part or all of what you requested, we must provide the coverage we have agreed to within 24 hours after we receive your request or doctor’s statement supporting your request.

Step 3 – Filing an appeal

If we say no, to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you not to appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

For information on appeals, please go to our Appeals process page. You may also see information on Coverage Determination in Chapter 9, Sections 1-10 of the Evidence of Coverage (EOC).

You may submit feedback or complaints about your Medicare Advantage health plan directly to Medicare.

Prescription drug reimbursement

If you would like to submit a claim to be reimbursed for a prescription you paid out of pocket for at a non-participating pharmacy use the Direct Member Reimbursement (DMR) form:
DMR form English (PDF, 64 KB)
DMR form, Spanish (PDF, 89 KB)