Medicare Coverage Drug Request Form Instructions

To submit the Medicare Drug Request Form, you can send it by mail or fax. Mail the completed form to Express Scripts, Attn: Medicare Reviews, P.O. Box 66571, St. Louis, MO 63166-6571. Alternatively, fax it to 1-877-328-9799. If you prefer, you can also contact Express Scripts at 1-800-935-6103 for assistance.

Important dates for this form include enrollment periods and deadlines for submitting coverage determinations. Enrollees should be aware of the annual Medicare enrollment period, typically from October 15 to December 7. Other specific deadlines may apply based on individual healthcare plans and requests.

The purpose of this form is to request a coverage determination for Medicare Part D prescription drugs. Enrollees may need to ask for exceptions to formularies, prior authorizations, or tiering reductions. Properly completing this form ensures that patients receive timely access to necessary medications.

• 1. Enrollee's Information: Includes personal details about the enrollee like name, address, and member ID.
• 2. Requestor's Information: This section is for individuals submitting the request on the enrollee's behalf.
• 3. Drug Information: Details the requested prescription drug, including its strength and dosage.
• 4. Prescriber's Information: Includes the prescriber's details and professional information.
• 5. Supporting Information: Additional documentation that may be required to support the request.

Failing to submit this form may result in delays in obtaining necessary medications. It can also lead to a denial of coverage, forcing patients to cover costs out-of-pocket. Moreover, incomplete submissions may necessitate follow-up actions which can further delay access to required therapies.

• Delayed Medication Access: Patients may face delays in receiving their necessary medications, affecting their health.
• Out-of-Pocket Expenses: Without approval, patients may have to pay for medications themselves.
• Need for Additional Submissions: Incomplete forms may require the patient or prescriber to resubmit documents which delays the process.

• 1. Formulary Exceptions: Use when requesting a drug that is not on the approved list.
• 2. Prior Authorizations: Needed when special approval is required for a prescribed medication.
• 3. Tiering Exceptions: To appeal changes in drug tier classifications that affect copayments.