Blue cross blue shield tier exception form

Q: How do tier exceptions work?

For tiering exceptions, the prescribers supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollees condition, the preferred drug(s) would have adverse effects for the enrollee, or both.

You and your doctor can ask Horizon BCBSNJ to make an exception to cover a drug. If your doctor says that you have medical reasons to justify an exception, your doctor can help you request an exception. For example, you can ask the Horizon BCBSNJ to cover a drug even though it is not on your plan’s drug list, or you can ask the Horizon BCBSNJ to make an exception and cover the drug without restrictions.

Table of Contents Show

Health Benefits Claim Form
BCBS FEP Dental Claim Form
Health Benefits Election Form (SF 2809 Form)
Authorized Representative Designation Form
Medicare Reimbursement Account (MRA) Pay Me Back Claim Form
Retail Prescription Drug Claim Form
Mail Service Prescription Drug Form
Specialty Medication Order Form
Prior Approval Pharmacy Forms
Formulary Exception Form
Tier Exception Member Request Form
Dispense as Written (DAW) Exception Process
New to Market FDA-Approved Medication Review Exception Process
ACA Breast Cancer Prevention Coverage Member Request Form
ACA Bowel Prep Prevention Coverage Member Request Form
ACA HIV Prevention Coverage Member Request Form
Overseas Medical Claim Form
Retail Prescription Drug Claim Form
GMMI Overseas Provider Nomination Form
Prior authorizations
How do I request a prior authorization?
How do I request an exception?
Coverage determination about payment
Member forms
Start a coverage determination request online
Coverage determination request
Submit a direct member reimbursement form by mail
Provider forms
How do I get a Tier exception approved?
How do tier exceptions work?
How do you request a formulary exception?
What is the difference between formulary exception and prior authorization?

Your doctor must submit a formulary exception or tier exception request form for approval. If the request is not approved by Horizon BCBSNJ, you can still purchase the medicine at your own expense.

Health Benefits Claim Form

If you use a provider outside of the network, you will need to complete and file a claim form for reimbursement.

Overseas members should use the Overseas Medical Claim Form.

BCBS FEP Dental Claim Form

If you take advantage of Service Benefit Plan dental benefits, you will need to complete and file a claim form for reimbursement.

Health Benefits Election Form (SF 2809 Form)

To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form.

Authorized Representative Designation Form

Use this form to select an individual or entity to act on your behalf during the disputed claims process. You can find detailed instructions on how to file an appeal in the Disputed Claims Process document.

Medicare Reimbursement Account (MRA) Pay Me Back Claim Form

Use this form to request reimbursement for Medicare Part B premium expenses.

Retail Prescription Drug Claim Form

Complete this claim form for any pharmacy services received.

Mail Service Prescription Drug Form

Use this form to order a mail order prescription.

Specialty Medication Order Form

Use this order form for specialty medications.

Prior Approval Pharmacy Forms

For more information about Pharmacy Prior Approval and the required forms visit the Prior Approval page.

Formulary Exception Form

The Formulary Exception process allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug(s). Select the list of exceptions for your plan.

Tier Exception Member Request Form

For all formulary tier exceptions you will need to complete and file a request form.

Dispense as Written (DAW) Exception Process

The Dispense as Written exception process allows for coverage of the brand drug without paying the difference in cost between brand and generic.

New to Market FDA-Approved Medication Review Exception Process

The New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if the member has met the requirements outlined.

ACA Breast Cancer Prevention Coverage Member Request Form

Complete the Member Request Form for Primary Breast Cancer Prevention Coverage.

ACA Bowel Prep Prevention Coverage Member Request Form

Complete the Member Request Form for ACA Bowel Prep Prevention Coverage.

ACA HIV Prevention Coverage Member Request Form

Complete the Member Request Form for ACA HIV Prevention Coverage.

Overseas Medical Claim Form

Overseas members will need to complete and file this claim form for any medical services received.

Retail Prescription Drug Claim Form

Overseas members will need to complete and file this claim form for any pharmacy services received.

GMMI Overseas Provider Nomination Form

Should you wish to request to recruit a facility or physician into the GMMI network, please complete this nomination form.

A coverage determination, also called a coverage decision, is a decision we make about your benefits and coverage or about the amount we will pay for your medications. An initial coverage decision about your Part D drugs is called a “coverage 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 decision.

Prior authorizations

You may need to ask us to cover a drug on your plan's formulary (list of covered drugs) 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)

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)

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

Use the coverage determination form if you are submitting by fax or mail.

Call the Customer Care number located on your Blue Shield member ID card. You may be asked to provide your doctor’s office phone or fax number.
Fax: (888) 697-8122
Mail: Blue Shield of California
PO Box 2080
Oakland, CA 94604-9716

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 our formulary.
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 provide a higher level of coverage for your 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 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.

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. Find the forms you need below.

You, your doctor, or other prescriber may also contact us directly to request an exception, or check on the status of a request by calling Customer Care at the number on your member ID card.

Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Preferred Generic Drugs tier or the Specialty Tier Drugs.

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.

Coverage determination about 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 coverage determination form if you are submitting by fax or mail.

Coverage determination request

Medicare Part D coverage request form for enrollees, English (PDF, 194 KB)
Medicare Part D coverage request form for enrollees, Español (PDF, 167 KB)

Submit a direct member reimbursement form by mail

The reimbursement form must be received within one year 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 Care at the number on your Blue Shield member ID card.

DMR form for Medicare members, English (PDF, 233 KB)
DMR form for Medicare members, Español (PDF, 144 KB)

Mail the completed DMR form to:
Blue Shield of California
P.O. Box 52066
Phoenix, AZ 85072-2066

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

Provider forms

Use this Prior Authorization Form (PDF, 141 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, 86 KB)
Tier Exception (PDF, 109 KB)

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

Hospice Form (PDF, 123 KB)

  Phone: (800) 535-9481 (TTY: 711), Monday through Friday from 8 a.m. – 6 p.m. PST
  Fax: (888) 697-8122
  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.

How do I get a Tier exception approved?

TIER EXCEPTION CRITERIA FOR APPROVAL The member must have tried at least three alternative formulary drugs that are on a lower tier and approved to treat the same condition as the requested drug AND the member either did not respond to or did not tolerate the formulary alternative drugs.

How do tier exceptions work?

For tiering exceptions, the prescriber's supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both.

How do you request a formulary exception?

Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.

What is the difference between formulary exception and prior authorization?

A formulary exception request is needed when the prescriber is requesting coverage for a non-formulary medication. Exception requests and prior authorization requests should be submitted using the same form – the Medication Coverage Request Form. What is a step therapy exception request?