2020

PLAN
INFORMACIÓN

Express Scripts Medicare Part D Exceptions, Coverage Determinations, Appeals & Transition Processes

As a member, you can ask Express Scripts Medicare to make an exception to our Medicare Part D coverage rules. Hay varios tipos de excepciones que puede solicitarnos.

  • Puede pedirnos que cubramos su medicamento aunque no esté incluido en nuestro vademécum. Please note, if we grant your request to cover a drug that is not on our formulary, you will need to pay the cost-sharing amount that applies to drugs in Tier 4 (Non-Preferred Drugs). You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
  • Puede pedirnos que cancelemos las restricciones o los límites a la cobertura de su medicamento. Por ejemplo, en el caso de ciertos medicamentos, este plan limita la cantidad que cubriremos. Si su medicamento tiene un límite con respecto a la cantidad, puede solicitarnos que cancelemos el límite y que cubramos una cantidad mayor.
  • If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug.
    • If the drug you're taking is a biological product, you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.
    • If the drug you're taking is a brand-name drug, you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand-name alternatives for treating your condition.
    • If the drug you're taking is a generic drug, you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

Generally, this plan will only approve your request for an exception if the alternative drugs or covered quantities included on the plan's formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Debe comunicarse con nosotros para solicitarnos que tomemos una decisión inicial de cobertura relativa a una excepción al vademécum, a las categorías o a las restricciones de utilización. Para solicitar una excepción al vademécum, a las categorías o a las restricciones de utilización, debe enviar una declaración en la que su médico avale su solicitud. Por lo general, debemos tomar una decisión en un lapso de 72 horas desde su solicitud.

If you would like to request a Medicare Part D coverage determination (such as an exception to the rules or restrictions 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 contact us as indicated in the table below.

Revisiones de la cobertura clínica inicial

Use this contact information if you need a coverage decision for a medication that is not on the formulary.

Your prescriber may also request a Coverage Review by using our online portal.

Cobertura administrativa
Revisiones y apelaciones

Use this contact information if you need a coverage decision about a restriction on a specific medication or want to request a lower cost-sharing amount, or if you need to file an appeal because your request was denied.

Apelaciones clínicas

Use this contact information if you need to file an appeal if your coverage review is denied.

Llámenos al número gratuito +(1) 844 374 7377, las 24 horas del día, los 7 días de la semana. Usuarios de TTY: llame al 1.800.716.3231. Call toll free 1.800.413.1328, Monday through Friday, 8 a.m. - 6 p.m.,
Central. Usuarios de TTY: llame al 1.800.716.3231.
Call toll free 1.844.374.7377, Monday through Friday, 8 a.m. - 8 p.m.,
Central. Usuarios de TTY: llame al 1.800.716.3231.
Fax a Coverage Determination form to: 1.877.251.5896 Fax a Coverage Determination form to: 1.877.328.9660 Fax a Coverage Redetermination form to: 1.877.852.4070
Mail a Coverage Determination form to:

Express Scripts
Attn: Revisiones de Medicare
P.O. Box 66571
St. Louis, MO 63166-6571
Mail a Coverage Determination form to:

Express Scripts
Attn: Medicare Administrative Department
P.O. Box 66587
St. Louis, MO 63166-6587
Mail a Coverage Redetermination form to:

Express Scripts
Attn: Apelaciones clínicas de Medicare
P.O. Box 66588
St. Louis, MO 63166-6588
Documento: Cuándo se debe utilizar:
Evidence of Coverage* Una vez inscrito, puede solicitar una excepción a nuestras reglas de cobertura. Consulte el capítulo 7 para obtener información sobre los procesos de presentación de quejas formales, determinación de cobertura (incluidas las excepciones) y apelaciones.
Formulario de designación de representante Una vez inscrito, si desea designar a una persona para que presente una queja, solicite una determinación de cobertura o solicite una apelación en su nombre, usted y la persona que acepte dicha designación deben completar este formulario (o un documento escrito equivalente) y presentarlo junto con la solicitud. Click here for further instructions on how to appoint a Medicare Part D representative.
Formulario de solicitud de determinación de cobertura de medicamentos recetados de Medicare For all coverage review requests, this form should be used to initiate the coverage review process. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.251.5896. Click here if you would like to submit your Medicare Part D coverage determination request form online.
Formulario de solicitud de redeterminación de cobertura Este formulario debe utilizarse para iniciar una apelación clínica a una solicitud de revisión de la cobertura rechazada anteriormente. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.852.4070. Click here if you would like to submit a Medicare Part D coverage redetermination request form online.

Express Scripts Medicare proceso de transición:

As a new or continuing member in our Medicare Part D plan, you may be taking drugs that are not on our formulary. O bien, puede estar tomando medicamentos que sí se encuentren en nuestro vademécum, cuando su capacidad para obtenerlos es limitada. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception for us to cover the drug you take. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary supply of a maximum 30-day supply at retail (unless you have a prescription written for fewer days) when you go to a network pharmacy within the first 90 days of the calendar year (or the first 90 days of your effective date if your coverage begins after the first of the year). After your first 30-day supply, we will not pay for these drugs unless your request for an exception is approved. For additional information on our transition policy or if you are a resident of a long-term care facility, please refer to the plan's Medicare Part D Evidence of Coverage.

Recursos adicionales:

Los formularios de solicitud de determinación de cobertura fueron desarrollados por los Centers for Medicare & Medicaid Services (CMS) para que los miembros y proveedores los utilicen cuando soliciten determinaciones de cobertura (incluidas las solicitudes de excepción) de planes de medicamentos recetados de Medicare. El uso de estos formularios modelo es óptimo.

Para acceder al formulario de solicitud de determinación de cobertura modelo de CMS para uso de los miembros, visite:
http://www.cms.gov/
Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovGenIn/downloads/
ModelCoverageDeterminationRequestForm.pdf

Para obtener instrucciones sobre cómo utilizar el formulario modelo Solicitud de determinación de cobertura de CMS, visite:
http://www.cms.gov/
Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovGenIn/downloads/
InstructionsModelCoverageDeterminationRequest.pdf

¿Necesita ayuda?

Call 1.866.477.5703 TTY users: 1.800.716.3231
8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas

* If you want an Evidence of Coverage mailed to you or if you have questions about plan details, please call 1.866.477.5703, 8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas. TTY users, call 1.800.716.3231. You may also email your request for an Evidence of Coverage to documents@express-scripts.com. Requests sent by email must include: Full name, telephone number and mailing address.

Express Scripts Medicare (PDP) es un plan de medicamentos recetados que tiene un contrato con Medicare.
La inscripción en Express Scripts Medicare depende de la renovación del contrato.

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