Coverage Determination / Redetermination / Appeals

If your doctor or pharmacist tells you that we will not cover a prescription drug you should contact us and ask for a Coverage Determination. The following are examples of when you may want to ask us for a Coverage Determination:

  • If there is a limit on the quantity (or dose) of a drug and you disagree with the requirement of dosage limitation.
  • If there is a requirement that you try another drug before we will pay for the drug you are requesting.
The process for requesting a Coverage Determination is discussed in more detail in the Evidence of Coverage /Certificate of Coverage (Chapter 9, Section 6) titled: "Your Part D prescription drugs: How to ask for a coverage decision or make an appeal".

Coverage Determination/Redetermination/Appeals Forms

These forms can be used for Coverage Determination / Redetermination / Appeals. Have a physician complete the appropriate form below and fax it to 1-800-693-6703 or mail it to Prime Therapeutics LLC, Attention: Clinical Review Department, 1305 Corporate Center Dr., Building N10, Eagan, MN 55121.

For additional assistance, or to file a medical organization determination, reconsideration, or appeal, contact Customer Service:

Blue Cross Medicare Advantage

1-877-774-8592
TTY/TDD: 711

Blue Cross Medicare Advantage (HMO SNP)

1-877-688-1813
TTY/TDD: 711

Blue Cross MedicareRx

1-888-285-2249
TTY/TDD: 711


We are open 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15th through September 30th, alternate technologies (for example, voicemail) will be used on the weekends and holidays. TTY/TDD: 711

Formulary Exception: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 and generic drugs. You can also request a tier exception for your non-preferred drug be covered at the preferred drug copay level. This applies to five-tier benefit plans only.

Blue Cross Medicare Advantage Formulary Exception Request Form.pdf
Blue Cross MedicareRx Formulary Exception Request Form.pdf

Blue Cross Medicare Advantage Tier Exception Request Form.pdf
Blue Cross MedicareRx Tier Exception Request Form.pdf

Prior Authorization: Required on some medications before your drug will be covered.

Quantity Limits: Applied to certain drugs based on the approved dosing limits established during the FDA approval process. Quantity limits are applied to the number of units dispensed for each prescription.

Step Therapy: Requires the previous use of one or more drugs before coverage of a different drug is provided.


CMS Request Forms

Below are CMS model forms developed specifically for use by all Part D prescribing physicians or enrollees. Any of the Model Part D Forms listed below will be accepted. Access the Medicare Part B versus Part D Form to determine coverage under the appropriate Medicare benefit.

Blue Cross Medicare Advantage (HMO)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross Medicare Advantage (HMO-POS)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross Medicare Advantage (PPO)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross Medicare Advantage (HMO SNP)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross MedicareRx Basic (PDP)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross MedicareRx Value (PDP)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

Blue Cross MedicareRx Plus (PDP)SM

Request for Coverage Determination Form
Request for Coverage Redetermination Form
Medicare Part B versus Part D Form
Hospice Determination Form

CMS Appointment of Representative

CMS Appointment of Representative Form
CMS Appointment of Representative Form (en español)


Blue Cross Medicare Advantage

This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592 (TTY/TDD users should call 711).

We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-877-774-8592 (los usuarios de TTY/TTD deben llamar al 711). Estamos a su disposión de 8:00 a.m. - 8:00 p.m., los siete días de la semana. Sí llama del 15 de febrero al 30 de septiembre, se utilizarán technologías alternas (por ejemplo, correo de voz) durante los fines de semana y días feriado.

Contact us at:
Blue Cross Medicare Advantage
P.O. Box 4555
Scranton, PA 18505

Plans available in Bernalillo, Cibola, Guadalupe, Los Alamos, Mora, Rio Arriba, San Miguel, Sandoval, Sante Fe, Socorro, Torrance, and Valencia counties.

Blue Cross Medicare Advantage and Blue Cross Medicare Advantage Dual Care plans are HMO, HMO-POS, PPO, and HMO Special Needs Plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. HCSC is Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program. Enrollment in HCSC's plans depends on contract renewal.


Blue Cross MedicareRx

This information is available for free in other languages. Please call our Customer Service number at 1-888-285-2249 (TTY/TDD users should call 711).

We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-888-285-2249 (los usuarios de TTY/TTD deben llamar al 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Sí llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán technologías alternas (por ejemplo, correo de voz).

Contact us at:
Blue Cross MedicareRx
P.O. Box 3897
Scranton, PA 18505-0897

MyPrime is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, an independent company providing pharmacy benefit management services.

SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans

® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans

Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company (HISC), an independent licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC's plan depends on contract renewal.

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© Prime Therapeutics LLC | This website was last updated January 01, 2014

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