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If your doctor or pharmacist tells you that we will not cover a prescription drug, you, as a Blue Cross MedicareRxSM member, should contact us and ask for a coverage determination. Contact a Product Specialist to obtain information on how to file a grievance, appeal, or exception with the plan sponsor.
Things to know about requesting an exception:
The Centers for Medicare & Medicaid Services (CMS) has a model Medicare prescription drug coverage determination form developed specifically for use by all Part D prescribing doctors and enrollees.
The formulary exception process is used to request coverage for a medication that's not on the drug formulary. All approvals for non-formulary medications will require a Tier 4 copay for brand name drugs or a Tier 2 copay for generic drugs. You can also request a tier exception for your non-preferred drug to be covered at the preferred drug copay level. In other words, you can request that your non-preferred brand name drug (Tier 4) be covered at the preferred brand name (Tier 3) copay level; or your non-preferred generic drug (Tier 2) be covered at the preferred generic drug (Tier 1) copay level. This applies to five-tier benefit plans only.
A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.
If you or your doctor do not agree with the outcome of the initial coverage determination, you or your doctor must appeal the decision by having your doctor request a redetermination. Your appeal may include: non-formulary, coverage rule, or tiering exceptions.