Part D Coverage Determination Process
Category: Part D Coverage Determinations & Appeals
A coverage determination is an initial coverage decision made by SCAN regarding your Medicare Part D prescription drug. Coverage determinations you can request about your Part D drugs include:
- 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 requires our approval before it is covered.)
- You can ask us to pay for a prescription drug you already bought.
- 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.”) Examples include:
- 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
Important Information to Know About Asking for Exceptions
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 the form below to submit your request for a Part D Coverage Determination:
Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner.
To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) should contact Express Scripts, Inc (ESI):
- You may Call ESI at (844) 424-8886. 24 hours a day, 7 days a week, TTY users: (800) 716-3231
- You may Fax your request to: 1-877-251-5896 (Attention: Medicare Reviews)
- You may also send your request via email to: firstname.lastname@example.org
- You may mail your request to:
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
For additional assistance in making your Part D Coverage Determination request you may call our Member Services Department.
To find out more about the Part D Coverage Redetermination Process, please refer to your Evidence of Coverage (EOC) -- see chapter 9, Section 6: "How to ask for a coverage decision or make an appeal." Or call Member Services at the number(s) listed above.