Part D Coverage Determination Process
An initial coverage decision about your Part D drugs is called a Coverage Determination.
Use this process to ask us to make a Part D drug Coverage Decision.
Here are examples of coverage decisions you can ask us to make about your Part D drugs:
1. You can ask whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs but we require you to get approval from us before we will cover it for you.)
2. You can ask us to pay for a prescription drug you already bought.
3. You can ask us for an exception. (If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an “exception”.)
Requests for exceptions are a type of coverage determination. Here are examples of exception requests:
Important Information to Know About Asking for Exceptions
- Asking for coverage of a drug that is not on the drug list
- Asking to pay a lower cost-sharing amount for a covered non-preferred drug
- Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
- Being required to use the generic version of a drug instead of the brand name drug
- Getting plan approval in advance before we will agree to cover a drug for you
- Quantity Limits
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception What to Do
You (or your representative or your doctor or other prescriber) may use one of the forms below to submit your request for a Part D Coverage Determination: Request for Medicare Prescription Drug Determination Request Form
Your doctor/prescriber may use one of the forms below to provide the medical reasons for the drug exception you are requesting: 2012 Non Formulary Drug Request Form 2012 Specialty General Request Form 2012 Tier Exception Request Form
To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) must contact Express Scripts, Inc (ESI):
- You may call ESI at 1-800-417-8164. 24 hours a day, 7 days a week, TTY users: 1-800-899-2114
- You may Fax your request to: 1-877-837-5922 (Attention: Prior Authorization Department – Part D)
- You may also send your request via email to: firstname.lastname@example.org
- You may mail your request to:
Express Scripts, Inc.
Attention: Prior Authorization Department - Part D
Mail Stop B401-03, 8640 Evans Road
St. Louis, MO 63134
For additional assistance in making your Part D Coverage Determination request you may call our Member Services Department at:
1-888-540-7226, 7:00 a.m. – 8:00 p.m, 7 days a week, TTY users: 711
To find out more details about the Part D Coverage Determination process refer to your Evidence of Coverage booklet, Chapter 9, Section 6. How to ask for a coverage decision or make an appeal. Or call our Member Services at the number(s) listed above.