A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. An initial coverage decision about your Part D drugs is called a “coverage determination.”

Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision.

The following are types of coverage decisions we may make for you:

  • You ask us to cover a drug on your plan's List of  Covered Drugs (Formulary) that needs prior approval, because you meet the coverage rules.

  • You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

  • You, your physician, other prescriber or your appointed representative can ask us to make an exception to our coverage rules. There are several types of exceptions you can request:

    • You can ask us to cover your drug even if it is not on our formulary.

    • You can ask us to waive coverage restrictions or limits on your drug. For example, Blue Shield limits the amount on certain drugs we cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

    • You can ask us to provide a higher level of coverage for your drug. For example if your drug is on the Non-Preferred Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Drug tier instead as long as there is a formulary drug that treats your condition on the Preferred Brand Drug tier. This would lower the amount you pay for your drugs.

Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Preferred Generic Drugs tier or the Specialty Tier Drugs. 

Generally, Blue Shield will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

 

For coverage determination and exception: 

Download and complete; Medicare's Part D coverage request form for enrollees (PDF, 117KB)

If a formulary or tiering exception is requested, your physician must provide a statement supporting your request. Your physician or other prescriber can refer to the Medicare Part D Prior Authorization forms page to download and complete a prior authorization or exception request.

You or your physician or other prescriber may also contact us directly to request a coverage determination or exception or check on the status of a request by calling Member Services at the appropriate number below.

For more information regarding the exception processplease call Member Services who may be reached at the additional times:

Blue Shield 65 Plus, Blue Shield 65 Plus Choice Plan, Blue Shield Trio Medicare, Blue Shield Inspire, Blue Shield Vital, and Blue Shield Medicare (PPO) Plan members:
(800) 776-4466 [TTY: 711] between 8 a.m. and 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday), from April 1 through September 30.

Blue Shield Medicare Prescription Drug Plan members: 
(888) 239-6469 [TTY: 711] between 8 a.m. and 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m., Saturday and Sunday), from April 1 through September 30.

To appoint a representative or authorize someone to act on your behalf, you and your representative must first sign and date a statement that gives this person legal permission to act as your authorized representative. This form must be completed and submitted before exception requests from your appointed representative can be reviewed. You can call Member Services to request a copy or download CMS' Appointment of Representation form (English / Spanish) in place of Blue Shield's form and send it to us:

By Fax: All plans - (916) 350-6510

By Mail: All Plans - Blue Shield of California Medicare Appeals & Grievances
PO Box 927, Woodland Hills CA 91365-9856