Coverage Exceptions, Grievances, Appeals and Prior

Coverage Exceptions, Grievances, Appeals and Prior Authorizations

Q1: What is an Exception (Coverage Determination)?
A1: Exceptions apply to prescription drug coverage only. There are three types of formulary exceptions you can ask us to:

  • Cover your drug even if it is not on our formulary.
  • Waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueAdvantagePlus limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • Provide a higher level of coverage for your drug. For example, if your drug is usually considered a third tier drug, you can ask us to cover it as a second tier instead. This would lower the amount you must pay for your drug. 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.

Generally, BlueAdvantagePlus will only approve your request for an exception if the alternative drug included on the BlueAdvantagePlus formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.

How to Request an Exception (Coverage Determination)

Under BlueAdvantagePlus, you can request a coverage determination, including a request for a tiering or formulary exception. A request can also be made on your behalf by your appointed representative or your prescribing physician. A request for a standard coverage determination is generally made in writing, but BlueAdvantagePlus accepts verbal requests. A request for an expedited coverage determination can be made verbally or in writing. You, your appointed representative, or your prescribing physician may submit a written request for a coverage determination in any format or you may use the Prescription Drug Coverage Determination form below.

To verbally request an exception or to check on the status of an exception, call Customer Service:

1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
Monday-Friday, 8 a.m. to 5 p.m. ET

To make your request in writing, you may complete the Prescription Drug Coverage Determination Form. Supporting statements from your physician are required. Mail or fax to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498


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Q2: What is a Grievance?
A2: If you have a problem with any of our medical or prescription drug policies and procedures, you may file a grievance. You cannot be dropped from the plan for making a complaint.

How to File a Grievance

You may call Customer Service to verbally file a grievance or to check on the status of a grievance:

1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
Monday-Friday, 8 a.m. to 5 p.m. ET

Complete the Grievance Form. Supporting statements from your physician are required. Mail or fax to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498


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Q3: What is an Appeal?
A3: If we deny a claim, service or coverage for a prescription drug, we will explain why. If you disagree with our decision regarding the handling of your claim or a denial of a service or prescription drug, you have the right to file an appeal. Your claim will be reviewed again. If you are still not satisfied with the decision, your appeal will be reviewed by an independent organization that works for Medicare.

How to File an Appeal

You may call Customer Service to verbally file an appeal or to check on the status of an appeal:

1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
Monday-Friday, 8 a.m. to 5 p.m. ET

Complete the Appeal Form. Supporting statements from your physician are required. Mail or fax to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498


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Q4: Appointing a Representative to Act on Your Behalf
A4: You may assign someone such as a relative, friend, advocate, an attorney or any physician to act as your representative and file an appeal for you. A representative may:

  • Obtain information about the enrollee's claim to the extent consistent
    with current Federal and state law;
  • Submit evidence;
  • Make statements of fact and law; and
  • Make any request, or give or receive any notice about the appeal
    proceedings.

Both you and your representative must sign, date and complete the Appointment of Representative form. If you want to assign a representative to ask for an appeal for you, this signed form must be filed with your appeal. Unless you decide you no longer want to have a representative, the form will be good for one year after the date you and your representative sign the form. If future appeals are filed during this time, your representative must file a photocopy of the signed representative form for each appeal. If your physician agrees to act as your representative and files an appeal for you, you cannot be charged by your physician for filing the appeal.

BlueAdvantage and BlueAdvantagePlus members only need to complete the first three sections of this form. Mail or fax the form to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498

More Detailed Information is Available

This information is a brief overview of the BlueAdvantage and BlueAdvantagePlus exception, grievance and appeals process.

BlueAdvantage members can review sections 9 and 10 of their Evidence of Coverage off-site link for detailed information on the appeals and grievance policies and procedures for medical coverage.

BlueAdvantagePlus members can review sections 10 and 11 their Evidence of Coverage off-site link for detailed information on the appeals and grievance policies and procedures for medical coverage. Exception policies and procedures for prescription drug coverage are located in section 6. Appeals and grievance policies and procedures for prescription drug coverage are located in section 12.


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Q5: How to Request a Prior Authorization
A5: How to Request a Prior Authorization

Prior authorizations are usually requested directly by your physician. However if you need to submit a request yourself, have your doctor complete the appropriate form and mail or fax it to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations
Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498

For prescription drugs that require prior authorization, please use the Prescription Drug Coverage Determination Form.

For medical prior authorizations, please use the appropriate form below:


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Page Modified:May 18, 2012