If a certain prescription requires a prior authorization or is exceeding a coverage limit, you can complete a Coverage Determination Request Form provided below if you want SCAN to assist in having your physician send medical justification to Express Scripts to make a decision on whether to cover your request.



A decision about whether SCAN will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard timeframe typically within 72 hours of receiving the request. You may ask for a “fast” decision (expedited review) only if your physician believes that waiting for a standard decision could seriously harm your health or your ability to function. If your request to expedite is granted, a decision will be made no later than 24 hours after we receive the request. Once a decision has been made, Express Scripts will send a letter to you and your physician regarding the decision of the coverage determination.

If you or your doctor/prescriber would like to submit the request to Express Scripts directly, one of the two forms listed below can be used.

Member Coverage Determination Form
Physician Coverage Determination Form

The written coverage determination form can be mailed to the following address:

You or your doctor/prescriber may also fax in your coverage determination request to Express Scripts at 1-877-837-5922 (Attention: Prior Authorization Department Part D).

To check the status of a coverage determination request or for additional assistance in making this request, please contact Member Services at 1-800-559-3500 (TTY Users: call 1-800-735-2929).

You can find detailed information regarding the Coverage Determination process in your Evidence of Coverage booklet under Chapter 9, Section 6: Your Part D Prescription Drugs: How to ask for a Coverage Determination or make an Appeal.