Services
Resources for Express Scripts MedicareTM Prescription Plan Members
Express Scripts Medicare Formulary
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.
- Value Plan (PDF file)
- Choice Plan (PDF file)
Formulary Changes for Express Scripts Medicare Part D Prescription Drug Plans
View the list of drugs that have quantity limits, step therapy, or prior authorization requirements and the rules that apply to each drug.
Value Plan
- Prior Authorization Criteria (PDF file)
- Step Therapy Criteria (PDF file)
- Quantity Limits for Formulary Medications (PDF file)
Choice Plan
- Prior Authorization Criteria (PDF file)
- Step Therapy Criteria (PDF file)
- Quantity Limits for Formulary Medications (PDF file)
Coverage Review Request Form
To initiate the coverage review process, use the Request for Medicare Prescription Drug Coverage Determination form (PDF file), submit a coverage determination request form online, or call us toll-free at 1.800.935.6103, 24 hours a day, 7 days a week. For the hearing-impaired with a TTY machine, please call 1.800.716.3231.
CMS Request for Medicare Prescription Drug Coverage Determination form (PDF file)
Redetermination Request Form
To initiate an appeal of a previously declined coverage review request, submit a coverage redetermination request form online, or call us toll-free at 1.800.935.6103, 24 hours a day, 7 days a week. For the hearing-impaired with a TTY machine, please call 1.800.716.3231.
More Drug per Dispensing Request Form
Use the More Drug Per Dispensing form (PDF file) to request more drugs per dispensing.
Express Scripts Foundation