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Part D Drug Exceptions and Appeals

If you have a medically necessary need for a non-formulary drug, you can ask us to make an exception and cover the drug. We respond to exception and appeal requests within 72 hours. There are three types of exceptions that you can ask for.

  •  Coverage for a drug, even if it is not on our drug list.
  • Waiving coverage restrictions or limits on a drug.
  • Lowering the tier cost of a drug.

If we deny your exception request, we will mail you a letter explaining why your request was denied. This letter will include how you can appeal our decision. You can ask for a standard or expedited appeal.

  • For standard appeals, we must provide a decision no later than seven days after we get your appeal request.
  • Ask for an expedited (fast) appeal when you or your doctor believes that your health could be seriously harmed by waiting up to seven days for a decision. We will give you a decision no later than 72 hours after we get you expedited appeal request.

If your prescribing doctor supports your expedited appeal or requests an expedited appeal for you, we automatically grant you a faster decision. If you request an expedited appeal without support from a doctor, we determine whether or not your health situation requires a fast appeal. In the event we determine your situation does not require a fast decision, we give you a decision within 7 days. We will not expedite an appeal for a drug you already receive.

How to request an appeal

  • Expedited Appeals: You or your appointed representative should contact us by telephone at 1-855-344-0930, TTY 1-866-236-1069 or fax at 1-855-633-7673.
  • Standard Appeals: You or your appointed representative should mail your written appeal request to CVS Caremark, Attention: Prior Authorization – Part D, 620 Epsilon Drive, Pittsburgh, PA 15238

Your appeal should include

  • Your name
  • Address
  • Member ID number
  • Reason(s) for your appeal
  • Evidence supporting your need for an appeal
  • If your appeal relates to denial by us for a drug that is not on our drug list, your prescribing doctor must indicate that none of the drugs on any tier of our drug list would be as effective to treat your condition as the requested drug.

Next Steps

We will review your appeal and give you a decision. If we deny an appeal, you can request an outside review by an independent reviewer not associated with our plan.

If you disagree with that decision, you still have the right to further appeal. We will notify you of your appeal rights if this happens.

Our contact information

If you need help with an appeal, call Customer Service at 1-888-494-2583 or TTY 1-800-377-1363, 8 a.m. to 8 p.m., seven days a week.

Other Resources

  • Medicare Rights Center,1-888-HMO-9050
  • 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048

2014 Tools, Resources & Other Information

Drug List (Formulary) & Prescription Drug Resources

Membership Information

Member Handbook

Summary of Benefits

Evidence of Coverage

Annual Notice of Change

Other Plan and Benefit Information

Medicare beneficiaries may enroll in Blue Cross of Idaho Medicare Advantage plans through the CMS Medicare Online Enrollment Center located at


Submit feedback about your health plan directly to Medicare, or find Medicare contacts, such as your State of Idaho Ombudsman.


Call from 8 am to 8 pm
7 days a week

Toll-Free: 1-888-492-2583
TTY 1-800-377-1363


3000 E Pine Ave.
Meridian, ID 83642-5996

P.O. Box 8406
Boise ID 83707-2406

If you have special needs, the information on this site may be available in other formats or languages. To find out more call 1-888-494-2583.

Blue Cross of Idaho Care Plus is a PPO, HMO or HMO POS health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus depends on contract renewal.

Blue Cross of Idaho Care Plus, Inc. Code of Ethical Business Conduct (PDF 180K)pdf download


Blue Cross of Idaho Care Plus Notice of Privacy Practices

Need more help deciding which type of coverage fits your needs? Attend a seminar or find a certified agent.

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Last updated 1-31-2014