Express Scripts Appeal Form - Norwalk 2026

1. Click ‘Get Form’ to open the Express Scripts Appeal Form - Norwalk in the editor.
2. Begin with Section A: Claimant Information. Enter your Member I.D. Number and specify if the request is for a Medicare Prescription Drug Plan. Fill in your first name, middle initial, last name, and address.
3. Provide your daytime and evening telephone numbers, ensuring to include area codes. Indicate your gender by checking either the 'Male' or 'Female' box and enter your birth date in the designated field.
4. In Section B: Medication Information, input the drug name, strength, dosage form, quantity, and date(s) of service.
5. Proceed to Section C: Physician Information. Enter the prescribing physician's name, address, city, state, zip code, and telephone number.
6. In Section D: Coverage Request, describe your coverage request in detail. If necessary, attach an additional page for more information regarding your health condition or include a supporting letter from your physician.
7. Finally, complete the form and mail or fax it to the appropriate address provided in Section E based on whether you are under a Non-Medicare or Medicare plan.

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