Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSMT members.
Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.
The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.
You can view your drug list here. Be sure to choose the section that describes your plan.
When You Can Request a Coverage Exception
If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.
To request this exception, your prescribing doctor will need to send BCBSMT documentation. To begin this process, you or your doctor should call the BCBSMT Customer Service number listed on your member ID card for more information.
You can also fill out and submit the Prescription Drug Coverage Exception form. You will need to provide us with your doctor's name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.
BCBSMT will usually let you or your doctor know of the benefit coverage decision within 72 hours of receiving your request. If the coverage request is denied, BCBSMT will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination (see below for more information).
You or your doctor may be able to ask for an expedited review if:
- You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
- Your current drug therapy uses a non-covered drug
- If your review is expedited, BCBSMT will usually let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSMT will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.
How to Request Reconsideration of a Drug Coverage Exception Determination
If your coverage request is denied, you may request an external review with an Independent Review Organization (IRO). If your case qualifies for external review, an IRO will review your case, at no cost to you, and make a final decision.
To ask for an external review, you'll need to complete a form and submit it to BCBSMT. You may get a form by calling the number on the back of your ID card.
Submit this form to:
Blue Cross and Blue Shield of Montana
P.O. Box 4309
Helena, MT 59604
If it is determined that your request does not qualify for external review, you may file an appeal of that determination with the Commissioner of Securities and Insurance (CSI). You may contact the CSI at the following address:
Commissioner of Securities and Insurance
840 Helena Avenue
Helena, Montana 59601
If you have any questions about requesting a coverage exception, call the Customer Service number listed on your member ID card.