External review for approval of a drug your plan doesn't cover

What is this about?

If you requested approval for a prescription drug that your HMO or PPO plan doesn't cover and we denied your request, this information tells you how to request an external review.

If we denied your request to approve a prescription drug that your plan doesn’t cover, you or an authorized representative may be eligible for external review by an independent review organization, or IRO. If applicable, we’ll also include an external review form with your denial letter. 

You'll need to request a review within four months of the date you received our decision.

How to request a review

Please mail the following:

  1. A completed external review form:
  2. A copy of our decision
  3. A statement from your doctor explaining:
    • Why the covered drugs are ineffective or have a negative health effect
    • Why the drug you're requesting would be more effective

Mailing address for PPO members

 
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BCBSM External Review Requests                               
Blue Cross Blue Shield of Michigan
600 Lafayette East — Mail Code CS3A
Detroit, MI 48226-2998

Mailling address for HMO members

 
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Appeals and Grievance Unit — Pharmacy External Review
Blue Care Network
P.O. Box 284
Southfield, MI 48037-0284

As soon as we get your request, we'll assign your case to an IRO. They'll inform you of their decision within 72 hours.

If they determine that we should cover the drug, we'll abide by their decision and cover the drug for the duration of the prescription, including refills.

Urgent external review

If we denied your request and your circumstances are urgent, you may be able to request an urgent external review by an IRO.

You may qualify for an urgent review if:

  • You're already going through a treatment with a drug that isn't listed on the pharmacy drug list.
  • Your health condition could be life threatening or you may lose the ability to regain full bodily function.
  • The timeframe of 72 hours would seriously jeopardize your life or health.

How to request an urgent external review

Within 10 days of receiving our denial, you or an authorized representative will need to call one of the following numbers:

  • For PPO members: 313-225-0646
  • For HMO members: Call the number on the back of your Blue Cross ID card.

Immediately after receiving your request, we'll assign your case to an IRO. They'll inform you of their decision within 24 hours of receiving your request.

If you have any other questions, please call the number on the back of your Blue Cross ID card.