Coverage determinations

A coverage determination/organization determination is a decision we make about your benefits. This can be a decision about how we cover a drug or how much you pay for the drug.

A coverage determination/organization determination is also referred to as an "initial determination".

There are several different types of coverage determinations you can request:

• Prior authorization
• Coverage decision about payment
• Exception

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 determination.

Prior authorizations

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

How do I request a prior authorization?

To request a prior authorization for a drug, you, your healthcare provider, or appointed representative need to contact Blue Shield of California and provide clinical information. If the necessary information is not submitted, or the information does not meet the prior authorization criteria, the drug may not be covered. Learn more about what clinical information may be required below.

Clinical information for your prior authorization request

For a prior authorization request to be considered for approval, a doctor must provide clinical information which may include, but is not limited to, the following:

• The diagnosis or reason(s) you are being treated with the drug
• Lab test information (for example, LDL level for cholesterol treatment or the hemoglobin A1C level for diabetes treatment) 

or

• Your doctor's specialty or whether you have been evaluated by a specialist
• What other treatment(s) has been attempted, whether it was effective, or whether you experienced side effects from the treatment(s)

or

• What dose is required and how long your expected treatment is
• Whether a generic drug alternative is medically appropriate for you

Use the Medicare Part D coverage request form in the member forms section if you are submitting by fax or mail.

 Phone: Call the Customer Service number located on your Blue Shield member ID card. You may be asked to provide your doctor’s office phone or fax number.
 Fax: (844) 958-0934

 Mail:
Blue Shield of California
PO Box 2080
Oakland, CA 94604-9716
 

Exceptions

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

• You can ask us to cover your drug even if it is not on your plan’s drug list.
• You can ask us to waive coverage restrictions or limits on your drug. For example, we limit the quantity 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 lower your cost-share of a drug. For example, if your drug is in 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 or Generic Drug tier, so long as there is a formulary drug that treats your condition on this tier. This would lower the amount you pay for your medications.

Please note: If we grant your request to cover a drug that is not on your plan’s drug list, you may not ask us to lower the cost-share of that drug. Also, you may not ask us to lower the cost-share for drugs that are in the Preferred Generic or Specialty Tiers.

How do I request an exception?

Submit an exception by fax or mail
If you request a formulary or tiering exception, your doctor must provide a statement supporting your request. You will find the Medicare Part D coverage request form in the Member forms section.

You, your healthcare provider, or appointed representative may also contact us directly to request an exception.

Generally, we 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 or would cause you to have adverse medical effects.

Request for payment

As an eligible Medicare Part D member, any time you pay out-of-pocket for a prescription that your pharmacy benefit plan covers, you can submit a request for reimbursement. This process is called direct member reimbursement or DMR.

You will find the DMR form in the Member forms section.

Member forms

Start a coverage determination request online

You may start the process to obtain prior authorization or an exception. Your doctor or an authorized member of their staff may then be required to provide supporting medical documentation. Your doctor can also contact Blue Shield's Pharmacy Services to request a prior authorization on your behalf.

Use the Medicare Part D coverage request form below if you are submitting by fax or mail.

Medicare Part D coverage request form for enrollees, English (PDF, 300 KB)
Medicare Part D coverage request form for enrollees, Español (PDF, 331 KB)
Medicare Part D coverage request form for enrollees, Arabic (PDF, 365 KB)
Medicare Part D coverage request form for enrollees, Armenian (PDF, 395 KB)
Medicare Part D coverage request form for enrollees, Simplified Chinese (PDF, 339 KB)
Medicare Part D coverage request form for enrollees, Traditional Chinese (PDF, 435 KB)
Medicare Part D coverage request form for enrollees, Farsi (PDF, 480 KB)
Medicare Part D coverage request form for enrollees, Khmer (PDF, 420 KB)
Medicare Part D coverage request form for enrollees, Korean (PDF, 486 KB)
Medicare Part D coverage request form for enrollees, Russian (PDF, 372 KB)
Medicare Part D coverage request form for enrollees, Tagalog (PDF, 312 KB)
Medicare Part D coverage request form for enrollees, Vietnamese (PDF, 550 KB)

Submit a direct member reimbursement form by mail

The reimbursement form must be received within three years from the date you paid for the service. Submission of the form is not a guarantee of payment. If you need help completing the DMR form, please contact your pharmacist or call Customer Service at the number on your Blue Shield member ID card. If you used a copay or discount card, we encourage you to submit a request for reimbursement so the amount you paid is applied to your maximum out-of-pocket or deductible, depending on your plan.

DMR form for Medicare members, English, (PDF, X KB)
DMR form for Medicare members, Español, (PDF, X KB)

Mail the completed DMR form to:
Claims Processing
1606 Ave. Ponce de Leon
San Juan, PR 00909-4830

If you need to authorize a representative, learn how on our Appointment of Representative page.

Provider forms

Use this Prior Authorization Form (PDF, 391 KB) to submit by mail or fax.

To submit a formulary or tiering exception, use the forms below:

Non-Formulary Exception and Quantity Limit Exception (PDF, X KB) 
Tier Exception (PDF, X KB)

To submit a request for review for Part D Drugs Unrelated to Hospice, use the form below:

Hospice Form (PDF, X KB)

 Phone: (844) 935-4977 (TTY: 711), Monday through Friday from 8 a.m. – 6 p.m. PST
 Fax: (844) 958-0934

 Mail:
Blue Shield of California
PO Box 2080
Oakland, CA 94604-9716

 Online: Log in to Provider Connection to submit an online Prior Authorization request.

If you need to authorize a representative, learn how to do this on our Appointment of Representative page.