Physician Resources for Medicare Plan Members

The Express Scripts Medicare Part D formularies are reviewed by a Pharmacy & Therapeutics Committee composed of physicians and pharmacists who have been approved by the Centers for Medicare & Medicaid Services (CMS).

The formulary is a list of the prescription drugs that are approved for coverage under the Express Scripts Medicare Plan. Be sure to select the formulary that applies to the member's plan option.

View the Formulary Changes for Express Scripts Medicare Part D Prescription Drug Plans.

View the list of drugs that have step therapy or prior authorization requirements and the rules that apply to each drug.

Value Plan:

Choice Plan:

Saver Plan:

Coverage determination and redetermination

To initiate the coverage review process or to initiate an appeal of a previously declined coverage review request, please use the resources below.

 

PDF File

 Online Application

 Coverage Review Request Form

Medicare Prescription Drug Coverage
Submit a coverage determination request form online

 Redetermination Request Form

Coverage Redetermination Request Form
Submit a coverage redetermination request form online

If you would like to request a coverage determination (such as an exception to the rules or restriction 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 about a restriction on a specific medication.

Phone (toll-free): 1.844.374.7377, 24 hours a day, 7 days a week.

TTY Users (toll-free): 1.800.716.3231

Fax the appropriate form to: 1.877.251.5896

Mail the appropriate form to: Express Scripts, Attn: Medicare Reviews; PO Box 66571; St. Louis, MO 63166-6571

Administrative coverage reviews and appeals

Use this contact information if you need a decision about whether or not a medication is covered and at what cost-sharing amount.

Phone (toll-free): 1.800.413.1328, Mon. through Fri., 8:00 a.m. - 6:00 p.m. Central Time

TTY Users (toll-free): 1.800.716.3231

Fax the appropriate form to: 1.877.328.9660

Mail the appropriate form to: Express Scripts, Attn: Medicare Administrative Appeals; PO Box 66587; St. Louis, MO 63166-6587

Clinical appeals

Use this information if you need to file an appeal about a restriction on a specific medication.

Phone (toll-free): 1.844.374.7377, Mon. through Fri., 8:00 a.m. - 8:00 p.m. Central Time

TTY Users (toll-free): 1.800.716.3231

Fax the appropriate form to: 1.877.852.4070

Mail the appropriate form to: Express Scripts, Attn: Medicare Clinical Appeals; PO Box 66588; St. Louis, MO 63166-6588