What is coverage determination?

Coverage determination, also called "coverage decision for a drug," is a decision that Blue Shield Promise Cal MediConnect Plan makes about your coverage of prescription 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 or supported by certain reference books. An initial coverage decision about your Part D drugs is called a "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 Customer Care via phone, fax, or mail.

  Phone:(855) 905-3825 [TTY: 711], 8 a.m. - 8 p.m., seven days a week.
  Fax: (866) 712-2731
  Blue Shield Promise Cal MediConnect Plan
Customer Care (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, 145 KB)

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, a "supporting statement" is required. Your doctor or other prescriber must give us the medical reasons why you need the We call this the “supporting statement.” Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and then fax or mail a written statement if necessary.

If you are asking us to pay you back for a Part B drug or product please refer to the Organization determination for reimbursement process.

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

Standard coverage decision

In 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 it.

If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.

If our answer is yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your request or after we get your doctor’s supporting statement.

Fast coverage decision

If your health requires it, you can ask us to give you a "fast coverage decision." Fast coverage decision means we will give you an answer within 24 hours after we get the request or your doctor’s supporting statement.

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

  1. You are asking for a drug you have not yet received. You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.
  2. Using the standard deadlines could cause serious harm to your health or hurt your ability to function.

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 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 your coverage request, you have the right to request an 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 6.5 of the Evidence of Coverage (EOC) / Member Handbook.

You may submit feedback or complaints about your Cal MediConnect Plan health plan directly to Medicare.