2018

PLAN
INFORMATION

Medicare Part D Documents & Forms


Enrollment Materials:  
Plan Summary The plan summary provides an overview of Express Scripts Medicare and the benefits you will receive when you enroll.
Summary of Benefits The Summary of Benefits provides a summary of what the plan covers and what you pay.
Enrollment Form You may also use this form to join Express Scripts Medicare. Print our online enrollment form and then complete and mail it to:
Express Scripts Medicare (PDP) Enrollment
P.O. Box 4345
Scranton, PA 18505
Star Ratings Report Each year, the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Part D plans based on a 5-star rating system. CMS considers how well the plans perform in different categories, including customer service, patient safety, and member experience and satisfaction.
Multi-Language Insert The Multi-Language Insert is a document that contains information about free language interpreter services available to you.
Formulary: The formulary is a list of prescription drugs that is approved for coverage under Express Scripts Medicare. Be sure to select the one that applies to your plan option. Learn more about our formulary.

Please note: The formulary may change at any time. You will receive notice when necessary.
Formulary changes: Express Scripts Medicare may add or remove drugs from our formulary during the year. Use these links to get updated information about formulary changes. You may also call Customer Service at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Prior Authorization Criteria: Step Therapy Criteria: Some drugs may have special rules associated with them. These rules may require that you receive prior approval before the drug will be covered or that you first try certain drugs to treat your medical condition before another drug will be covered. Use these documents to view the lists of drugs that have prior authorization or step therapy requirements and the rules that apply to each drug.
Evidence of Coverage The Evidence of Coverage provides details about the Express Scripts Medicare prescription drug plan. Note: If you were automatically enrolled in the plan by CMS, be sure to review the Evidence of Coverage Rider as well. See Chapter 7 for information about the grievance, coverage determination (including exceptions), and appeals processes.
Fraud, Waste or Abuse This document explains what you can do to help us if you suspect Medicare Part D fraud, waste or abuse.
Monthly Premium Chart As a member of Express Scripts Medicare, you will pay a monthly premium in addition to any premiums you may pay for Medicare Part A and Part B. The premium amount varies by plan and region. Use this document to see the monthly premiums in your state.
Extra Help Monthly Premium Chart If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium, annual deductible and drug costs will be lower. Use this document to see what your monthly premium would be if you qualify for Extra Help.
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. For further instructions on how to appoint a representative, click here.
Medicare Prescription Drug Coverage Determination For all coverage review requests other than formulary changes, 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. If you would like to submit your coverage determination request online, please click here.
Coverage Redetermination Request Form This form should be used to initiate an appeal of a previously declined coverage review request. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.852.4070. If you would like to submit a coverage redetermination request form online, please click here.

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