Coverage Request Form

If you have a Blue Cross Blue Shield of Michigan PPO plan, or a Blue Care Network HMO plan, you can fill out the form below for a standard or expedited review. You should fill out this form if you need a drug or contraceptive that's not included on your drug list.

The items below will help us understand your needs. Please check all that apply (minimum of one option).*
  • It is required that at least one check box is selected.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required. This is not a valid email.
This field is required. This is not a valid ZIP code.
This field is required. This is not a valid phone number.
This field is required.
This field is required.
This field is required.
This field is required. This is not a valid phone number.
This is not a valid fax number.
This field is required.
This field is required.

If you have questions or need help with the appeal process, call the customer service number listed on the back of your Blue Cross ID card.