Please select a topic below to learn more about:
Medicare must approve our plan each year
The Centers for Medicare & Medicaid Services (CMS) must approve Express Scripts Medicare each year. A beneficiary can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and CMS renews its approval of the plan.
All Medicare prescription drug plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare prescription drug plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.
Express Scripts Medicare® (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal.
A Part D – eligible beneficiary is defined as:
Additional Enrollment Information
Initial Enrollment Period
When you reach age 65, you have a 7-month period to enroll in a Medicare Part D plan:
If you join during the 3 months before you turn 65, your coverage will start on the first day of your birthday month. If you join during or after your birthday month, your coverage will begin on the first day of the next month.
If you are under 65 and eligible for Medicare due to a disability, you can enroll in a Medicare Part D plan during the 7-month period that begins:
For more information, call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Annual Enrollment Period
The Annual Enrollment Period runs from October 15 through December 7 each year. In general, enrollment is allowed only during the Annual Enrollment Period unless you recently became eligible for Medicare or qualify for a Special Enrollment Period. For more information, call Customer Service toll free at 1.866.477.5703, 8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Special Enrollment Period
A Special Enrollment Period is when a person, under certain circumstances, may enroll in, or disenroll from, a Medicare prescription drug plan at times other than during the Annual Enrollment Period. Examples of such circumstances may include receiving benefits from both Medicare and Medicaid; changing living situations (such as moving out of state or into a long-term care facility); losing creditable prescription drug coverage from an employer or other plan sponsor; or losing coverage because a plan no longer offers Medicare prescription drug coverage. For more information, call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Late Enrollment Penalty
The late enrollment penalty is 1% of the national average premium for every month you were without Medicare Part D prescription drug coverage or other creditable prescription drug coverage following your Initial Enrollment Period. Or, the penalty can be charged if you had a break in creditable prescription drug coverage of 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare's standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Medicare Part D coverage.
Members may disenroll from a prescription drug plan during one of the election periods by following these guidelines:
For more information about Voluntary Disenrollment, please call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231. Or contact Medicare at 1.800.MEDICARE (1.800.633.4227). TTY users, call 1.877.486.2048, 24 hours a day, 7 days a week.
Required Involuntary Disenrollment
A prescription drug plan organization must end your membership in the plan if any of the following situations occur:
For more information about Involuntary Disenrollment, please call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
If you would like to request a 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:
Initial Clinical Coverage Reviews
Use this contact information if you need a coverage decision for a medication that is not on the formulary.
Your prescriber may also request a Coverage Review by using our online portal.
|Administrative Coverage Reviews
Use this contact information if you need a coverage decision about a restriction on a specific medication or want to request a lower cost-sharing amount.
|Clinical and Administrative 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.
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|
Coverage Determination form to:
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
|Mail a Coverage Determination form to:
Attn: Medicare Administrative Department
P.O. Box 66587
St. Louis, MO 63166-6587
|Mail a Coverage Redetermination form to:
Attn: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Coverage Redetermination Request Form
The request for Medicare Prescription Drug Denial Form should be used to initiate an 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.
If you would like to appoint a person to file a grievance, request a coverage determination or exception or make an appeal on your behalf, you and the person accepting the appointment must fill out an Appointment of Representative 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.
Express Scripts Medicare Transition Process
As a new or continuing member in our 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 so that we will 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. 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.
You may be able to get Medicare Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Medicare Extra Help, call:
If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. However, it does not include any Medicare Part B premium you may have to pay.
Please note: If you have received assistance with your prescription drug costs from a charity and receive a refund, you should work directly with the charity to refund its portion.
Brand-Name & Generic Drugs
Express Scripts Medicare covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredients as a brand-name drug. Generic drugs usually cost less than brand-name drugs. FDA-approved generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as their brand-name counterparts.
The Express Scripts Medicare formulary includes brand and generic drugs most commonly prescribed for seniors. Learn more about covered drugs.
We may immediately remove a brand-name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. We may not tell you in advance before we make that change—even if you are currently taking the brand-name drug. If you are taking the brand-name drug at the time we make the change, we will provide you with information about the specific change(s) we made. This will also include information on the steps you may take to request an exception to cover the brand-name drug. You may not get this notice before we make the change.
Once in a while, a drug may be suddenly withdrawn because it has been found to be unsafe or removed from the market for another reason. If this happens, we will immediately remove the drug from the Drug List. If you are taking that drug, we will let you know of this change right away.
We may make other changes once the year has started that affect drugs you are taking. For instance, we might add a generic drug that is not new to the market to replace a brand-name drug or change the cost-sharing tier or add new restrictions to the brand-name drug. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We must give you at least 30 days’ notice or give you a 30-day refill of the drug you are taking at a network pharmacy. During this 30-day period, you should be working with your prescriber to switch to a different drug that we cover. Or you or your prescriber can ask us to make an exception and continue to cover the drug for you.
If any other changes happen for a drug you are taking (but not because of a market withdrawal, a generic drug replacing a brand-name drug, or other change noted in the sections above), the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug.
Certain drugs may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
You may request information about the total number of grievances, appeals, and exceptions that have been filed with Express Scripts Medicare, as well as about the outcomes of these disputes. Call Express Scripts Medicare Customer Service toll free at 1.800.758.4574 (New York State residents, call 1.800.758.4570), 24 hours a day, 7 days a week. This information is available for free in other languages. TTY users, call 1.800.716.3231.
The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.
To qualify for the MTM program, you must be eligible. Please see below for those details. If you qualify, you will be automatically enrolled into the program, and the service is provided at no additional cost to you. You may choose not to participate in the program, but it is recommended that you make use of this free service.
The MTM program is offered through a partnership between Express Scripts and SinfoniaRx. The MTM program is not considered a part of the plan’s benefit.
You may qualify for the MTM program if:
If you qualify for the MTM program, you will be contacted and have the chance to speak with a highly trained pharmacist or a pharmacist intern who works under the direct guidance of a pharmacist. During that call, the pharmacist or pharmacy intern will complete a comprehensive review of your medicines and talk with you about:
If you qualify for the MTM program, you will receive:
For information about the MTM program or to see if you qualify, you can call 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Note: The Medication Therapy Management Program is not considered a benefit.
If you have a Medigap (Medicare Supplement Insurance) policy that includes prescription drug coverage, you must contact your Medigap issuer to let them know that you have enrolled in a Medicare prescription drug plan. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your policy and lower your premium. Call your Medigap issuer for details.
As an Express Scripts Medicare member, you have access to a broad national network of pharmacies, including convenient home delivery service through the Express Scripts PharmacySM.
In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. Covered Medicare Part D drugs are available at out-of-network pharmacies under certain circumstances, such as illness while traveling outside the plan's service area where there is no retail network pharmacy. You may incur an additional cost for prescriptions filled at an out-of-network pharmacy. Please note that the pharmacies in our network now may change. For the most up-to-date information, visit our Medicare Part D pharmacy locator tool or call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231.
Pharmacy Access & Participation
This plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. We will fill prescriptions at out-of-network pharmacies under certain circumstances. Quantity limitations and restrictions may apply.
Long-term care and home infusion pharmacies may service a broad area. Therefore, you may need to look outside your immediate area for these types of providers.
To get current information about Express Scripts Medicare network pharmacies in your area, visit our Medicare Part D pharmacy locator tool. Inclusion in this list does not guarantee that a pharmacy continues to participate in our plan.
The Medicare program rates how well plans perform in different categories (for example, ratings from patients and customer service). You may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area. You can also download the plan ratings for this plan. Every year, Medicare evaluates plans based on a 5-star rating system.
As a member of our plan, you pay a monthly plan premium. In addition, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party, even if the Medicare Part D premium is $0. Click here to view a listing of Express Scripts Medicare premiums by plan and state.
If you are assessed a Medicare Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium.
If you would like to change your premium payment method, please contact Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231. Please note: If you do choose to change your method of payment, it may take up to 3 months for this change to take effect, and you may continue to be billed via the original method until your change takes effect.
This website is designed to provide access to online information regarding the Express Scripts Medicare Part D product offering. In connection with providing this information, there are times when we will ask for, or collect, personal information from you. As part of our commitment to honor your privacy, this policy will explain the approach we take in protecting and using the information that we gather from you on this website. For your ease and convenience, we make this notice available from every page of the website, identified as "Privacy," with a link to this notice.
The service area for the Saver and Value Medicare Part D plans includes all 50 states, the District of Columbia, and Puerto Rico. The service area for the Choice Medicare Part D plan includes all 50 states and the District of Columbia.
Express Scripts Medicare
Attn: Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307
If you need assistance or more information on filing a complaint, please call Customer Service toll free at the number listed above.
If you would like to submit feedback about your Medicare Part D prescription drug plan directly to Medicare, please complete their online form at:
You may also contact them by phone at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users, call 1.877.486.2048.