Notice: Change Effective Jan. 1, 2017

Effective Jan. 1, 2017, our Medicare Advantage plans will switch Pharmacy Benefit Manager (PBM) association from Prime Therapeutics to CVS/Caremark. CVS/Caremark is an independent company that manages pharmacy benefits on behalf of BlueCross BlueShield of South Carolina. As a result, the contact information for submitting coverage determination and redetermination requests will be different for 2016 fill dates and 2017 fill dates. Use this information based on the applicable fill date.

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.

For 2017 fill dates, request a coverage determination using one of these options:

 For 2016 and earlier fill dates, request a coverage determination or a redetermination using one of these options: