BlueCross BlueShield of South Carolina

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 a member requests a redetermination, the plan will review the coverage determination to see if the plan followed all the rules properly.

To request a coverage determination or redetermination, you can choose one of these options:

1. Complete a coverage determination request form or a redetermination request form and fax the completed request to us at 855-633-7673.
   

   Coverage Determination Request Forms

   MedBlue Rx^SM/MedBlue Rx^SM Plus
   Medicare Blue^SM/Medicare Blue^SM Plus
   

   Redetermination Request Forms

   MedBlue Rx^SM/MedBlue Rx^SM Plus
   Medicare Blue^SM/Medicare Blue^SM Plus 
2. Call us at 800-294-5979 to request a coverage determination or 866-884-9479 to request a redetermination.
3. Send an email to us at medhelp@bcbssc.com.