Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin by entering the enrollee’s information, including their name, date of birth, address, phone number, and member ID number. Ensure all details are accurate.
3. If someone other than the enrollee or prescriber is submitting the request, complete the requestor’s section, stating their name, relationship to the enrollee, and contact information.
4. Attach any required representation documentation if someone else is making the request on behalf of the enrollee.
5. Specify the name of the prescription drug being requested, including its strength and the quantity requested per month.
6. Indicate the type of coverage determination request by checking the appropriate box, such as formulary exception or prior authorization.
7. If necessary, provide any additional information that the Blue Cross Blue Shield should consider, and attach supporting documents if applicable.
8. If you believe an expedited decision is necessary for health reasons, check the corresponding box and provide a statement from the prescriber.
9. Sign and date the request form, ensuring all sections are completed accurately before submission.

Complete your Blue Cross Blue Shield Of MI document online today for a smooth coverage determination process.