Coverage Determinations and Redeterminations

A coverage determination is a decision a health plan makes about whether it covers a drug prescribed for a member. The plan also decides the amount, if any, it must pay for the drug. If a plan denies a member coverage for a drug his or her physician prescribes, the member can request a coverage determination.

If the member is not satisfied with the outcome of a coverage determination, the member can appeal the decision by requesting a redetermination. When you or a member requests a redetermination, the plan will review the coverage determination to see if the plan followed all the rules properly. Learn more about coverage determinations and redeterminations. (This link leads to a third party website. That company is solely responsible for the contents and privacy policy on its site.)

To request a coverage determination, choose one of these options:

  • Call 1-888-645-6025 (TTY 1-888-645-6023)
  • Fax your request to 1-800-693-6703.
  • Email your request to medhelp@bcbssc.com.
  • Complete a coverage determination form. (This link leads to a third party website. That company is solely responsible for the contents and privacy policy on its site.)

 To request a redetermination, choose one of these options:

  • Call 1-888-645-6025 (TTY 1-888-645-6023).
  •  Fax your request to 1-800-693-6703.
  • Email your request to medhelp@bcbssc.com.
  • Complete a redetermination form. (This link leads to a third party website. That company is solely responsible for the contents and privacy policy on its site.)