2018

PLAN
INFORMATION

Express Scripts Medicare Part D Exceptions, Coverage Determinations, Appeals & Transition Process

As a member, you can ask Express Scripts Medicare to make an exception to our Medicare Part D coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, this plan 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.
  • You can ask to pay a lower cost-sharing amount for drugs in Tiers 2 and 4, as well as generic drugs included in Tier 3.

Generally, this plan will only approve your request for an exception if the alternative drugs or covered quantities included on the plan's formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Members may contact us to ask for an initial coverage decision for a formulary exception. When you are requesting an exception, you should submit a statement from your doctor supporting your request. Generally, we must make our decision within 72 hours of your request.

If you would like to request a Medicare Part D coverage determination (such as an exception to the rules or restrictions on our plan's coverage of a drug) or if you would like to make an appeal for us to reconsider a coverage decision, you may contact us as indicated in the table below.

Initial Clinical Coverage Reviews

Use this contact information if you need a coverage decision for a medication that is not on the formulary.

Administrative Coverage
Reviews and Appeals

Use this contact information if you need a coverage decision about a restriction on a specific medication and want to request a lower cost-sharing amount, or if you need to file an appeal because your request was denied.

Clinical Appeals

Use this contact information if you need to file an appeal if your coverage review is denied.

Call toll free 1.844.374.7377, 24 hours a day, 7 days a week. TTY users, call 1.800.716.3231. Call toll free 1.800.413.1328, Monday through Friday, 8 a.m. - 6 p.m.,
Central. TTY users, call 1.800.716.3231.
Call toll free 1.844.374.7377, Monday through Friday, 8 a.m. - 8 p.m.,
Central. TTY users, call 1.800.716.3231.
Fax a Coverage Determination form to: 1.877.251.5896 Fax a Coverage Determination form to: 1.877.328.9660 Fax a Coverage Redetermination form to: 1.877.852.4070
Mail a Coverage Determination form to:

Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Mail a Coverage Determination form to:

Express Scripts
Attn: Medicare Administrative Department
P.O. Box 66587
St. Louis, MO 63166-6587
Mail a Coverage Redetermination form to:

Express Scripts
Attn: Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Document: When to use:
Coverage Determination & Appeals
(Evidence of Coverage)
Once enrolled, you may request an exception to our coverage rules.
Appointment of Representative Form Once enrolled, if you would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf, you and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. Click here for further instructions on how to appoint a Medicare Part D representative.
Medicare Prescription Drug Coverage Determination Request Form For all coverage review requests, this form should be used to initiate the coverage review process. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.251.5896. Click here if you would like to submit your Medicare Part D coverage determination request form online.
Coverage Redetermination Request Form This form should be used to initiate a clinical appeal to a previously declined coverage review request. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.852.4070. Click here if you would like to submit a Medicare Part D coverage redetermination request form online.

Please note:
In some cases, you may not get the full amount of Medicare Extra Help you deserve because information about your income status is out of date. To address this issue, the Centers for Medicare & Medicaid Services (CMS) has created the Best Available Evidence (BAE) policy. Under this policy, if you show proof that you qualify for Extra Help, the plan must adjust the amount that you pay. For more information on the BAE policy, please visit the CMS website at:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/
17_Best_Available_Evidence_Policy.asp

Express Scripts Medicare Transition Process:

As a new or continuing member in our Medicare Part D plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary, but your ability to get it is limited. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception for us to cover the drug you take. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary supply for a maximum 30 days at retail (unless you have a prescription written for fewer days) when you go to a network pharmacy within the first 90 days of the calendar year (or the first 90 days of your effective date if your coverage begins after the first of the year). After your first 30-day supply, we will not pay for these drugs unless your request for an exception is approved. For additional information on our transition policy or if you are a resident of a long-term care facility, please refer to the plan's Medicare Part D Evidence of Coverage.

Additional Resources:

Coverage determination request forms were developed by the Centers for Medicare & Medicaid Services (CMS) for use by members and providers when requesting coverage determinations (including exception requests) from Medicare prescription drug plans. Use of these model forms is optional.

Enrollees/Members:

To access the CMS model Coverage Determination Request Form for use by members, visit:
http://www.cms.gov/
MedPrescriptDrugApplGriev/Downloads/
ModelCoverageDeterminationRequestForm.pdf

For instructions on how to use the CMS model Coverage Determination Request Form, visit:
http://www.cms.gov/
MedPrescriptDrugApplGriev/Downloads/
ModelCoverageDeterminationRequestInstructions.pdf

Providers:

To access the CMS model Coverage Determination Request Form for use by providers, visit:
http://www.cms.gov/Medicare/Appeals-and-Grievances/
MedPrescriptDrugApplGriev/downloads/
PhysicianCoverageDeterminationRequestForm.pdf

Need help?

Call 1.866.477.5703 TTY users: 1.800.716.3231
8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.
Enrollment in Express Scripts Medicare depends on contract renewal.