Prescription Drug Coverage Determination Request

If there is a restriction for a drug, it usually means that you, the provider, or your patient will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for your patient, a coverage determination is required.

Who can initiate a coverage determination?

You or your patient can ask us to make an exception for a drug if you feel we should cover a drug without having restrictions apply. If you believe your patient has medical reasons that justify asking us for an exception, you can help your patient request an exception to the rule.

Requesting a coverage determination

You or your patient can request a coverage determination by contacting Express Scripts. A coverage determination may be requested by:

*If you initiate a request through PromptPA for a Virginia Premier member, you will need to add “ *VPE ” to their member ID number, for example 1234567*VPE

How long will it take to get a decision?

Once we receive your written statement with the medical reasons for the exception request, we will notify you and your patient of our decision no later than 24 hours for an expedited request, or 72 hours for a standard request. We will notify you by telephone, and we will also send you and your patient a written notice of the decision.

We may expedite a request if we determine, or you inform us, that your patient’s life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.

What if the coverage determination was denied?

If the request is denied, you or your patient has the right to appeal by asking for a review of our decision. You or your patient must request this appeal within 60 calendar days from the date of our decision. You or your patient may request the appeal be standard or expedited.

Once we receive your statement or another prescriber’s statement, we will notify your patient of our decision no later than 72 hours for an expedited request, or 7 days for a standard request. An appeal can be requested by:

  • Calling us at 1-800-935-6103 (TTY: 1-800-716-3231) OR
  • Mailing:
    Express Scripts
    Attn: Medicare Reviews
    PO Box 66571
    St Louis, MO 63166-6571

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