2017 Forms & Updates
for BlueJourney PPO and BlueJourney HMO
As a member, you are entitled to file a grievance if you are dissatisfied with our service, plan, or providers. You are also entitled to appeal a denial of payment, eligibility or other decision. The following links provide the information needed to complete and file grievances and appeals, prescription drug coverage determination request or representative forms:

Appointing a Representative

If you want a friend, relative, your doctor or other provider, or other person to be your representative, you will need to complete the Appointment of Representative form. This will give that person the ability to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Obtaining a Coverage Decision

Members of BlueJourney PPO and BlueJourney HMO may ask us to make a coverage decision about a service or drug. To request an expedited coverage decision about your medical care, please contact BlueJourney HMO at 800.779.6962 or BlueJourney PPO at 866.987.4213  (TTY: 711). To request an expedited coverage decision for a Part D drug, please contact CVS/caremark - BlueJourney HMO at 800.844.0719 or BlueJourney PPO at 800.861.1737 (TTY: 711).

Standard coverage decisions must be in writing. Please send these requests to:

BlueJourney HMO Organizational Determinations  (or) 
BlueJourney PPO Organizational Determinations
PO Box 773733
Harrisburg PA 17177-3733

PO Box 52000, MC109
Phoenix, AZ 85072-2000
Attention: PA Department

Obtaining Data on Exceptions, Appeals and Grievances

Members of BlueJourney PPO and BlueJourney HMO can receive a description of the plans’ total number of exceptions, appeals and grievances received and how these cases were resolved. Contact BlueJourney PPO and BlueJourney HMO by phone or in writing.

Effective Date
NCD Description
July 29, 2015
October 9, 2014
October 30, 2013


Updated July 31, 2017
Y0016_17_401 Pending 05162017