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Home Medicare Coverage Resources

Medicare Coverage Determination and Redetermination

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

Coverage review request form

If you would like to initiate the coverage review process:

 

Redetermination request form

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