If a member is requesting a coverage determination or an exception, please fill out the appropriate form below and fax your request to Express Scripts at 877-837-5922.

A decision about whether SCAN will cover a Part D prescription drug can be a “standard” coverage determination (prior authorization) that is made within the standard timeframe typically within 72 hours. Turn around times for non-formulary exceptions and tier exceptions are typically within 72 hours upon receipt of completed information. If incomplete information is given, then the turnaround time will be delayed up to 14 days. Once a decision has been made, Express Scripts will send a letter to the physician’s office and the member regarding the decision of the coverage determination.

To check the status of a coverage determination and exception request, please call Express Scripts at 800-417-8164.

2010 Non-Formulary drug Request form 2010 Specialty General Request Form (Revised) 2010 Tier Exception Request Form Adagen-pegademase bovine Adcirca-tadalafil Afinitor-everolimus Aldurazyme-laronidase Anadrol-50-oxymetholone Anagrelide-anagrelide Aranesp-darbepoetin alfa B vs. D Gammagard-immune globulin B vs. D Gamunex-immune globulin B vs. D Mitoxantrone-mitoxantrone B vs. D Vidaza-azacitidine B vs. D-Anti-Cancer B vs. D-Anti-Emetics inj B vs. D-Engreix-B-hepatitis B vaccine B vs. D-Immunosuppressants B vs. D-Oral Anti-Emetics B vs. D-Recombivax HB-hepatitis B vaccine Betaseron-interferon beta 1b Byetta-exenatide Campath-alemtuzumab Cancidas-caspofungin Copaxone-glatiramer Elitek-rasburicase Emend-aprepitant Enbrel-etanercept Entocort EC-budesonide Fentanyl citrate lozenges-fentanyl citrate Forteo-teriparatide Genotropin-somatropin Gleevec-imatinib Humira Crohns-adalimumab Humira-adalimumab Increlex-mecasermine Liptior 80mg-atovastatin

Lovaza-omega-3-acid-ethyl esters Lyrica-pregabalin Miacalcin Inject-calcitonin salmon Naglazyme-galsulfase Neupogen-filgrastim Neutrexin-trimetrexate glucronate Nexavar-sorafenib Noxafil-posaconazole Ontak-denileukin diftitox Orfadin-nitisinone Peg Intron-peginterferon alfa Pegasys-interferon alfa-2a Procrit-epoetin alfa Proleukin-aldesleukin Provigil-modafinil Ranexa- ranolazine Relistor-methylnaltrexone Remicade-infliximab Revatio-sildenafil citrate Rituxan-rituximab Simponi-golimumab Somavert-pegvisomant Soriatane and Soriatane CK-acitretin Sprycel-dasatinib Strattera-atomoxetine Sutent-sunitinib Symlin and Symlinpen-pramlintide acetate Targretin-bexarotene Tasigna-nilotinib Thalomid-thalidomide Thioguanine-thioguanine Trisenox-arsenic trioxide Tykerb-lapatinib Velcade-bortezomib Votrient-pazopanib Zavesca-miglustat Zolinza-vorinostat

To view all of the Prior Authorization Criteria please click here



Physician Coverage Determination Link