Thank you for submitting your coverage determination form electronically.

This message confirms that your coverage determination form has been received and submitted successfully to Blue MedicareRx Insurance Company.

If you, or your prescribing physician, believe that waiting for a standard decision (which will be provide within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life or health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician’s support, we will decide if your health condition requires a fast decision.

Please refer to your Evidence of Coverage which outlines all of the details of your benefit regarding appeals, coverage determinations, or grievances.

For more information about our plans, the formulary, or to find a participating pharmacy, visit our Blue MedicareRx Web site. If you have any questions, please contact Customer Support, 24 hours a day, 7 days a week, per the number on the back of your Blue MedicareRx Id card.