Benefit Coverage Request Form 2025

1. Click ‘Get Form’ to open the Benefit Coverage Request Form in our editor.
2. In Section A, enter your Member I.D. Number and specify if the request is for a Medicare Prescription Drug Plan. Fill in the patient's name, address, gender, and date of birth.
3. Indicate the relationship of the patient to the cardholder by checking the appropriate box.
4. Move to Section B and indicate who is making the coverage request. If applicable, attach form CMS 1696 for appointed representatives.
5. In Section C, provide detailed medication information including drug name, strength, dosage form, quantity, and dates of service. Use additional pages if necessary.
6. Complete Section D by entering the prescribing physician's details including their name, address, NPI number, and phone number.
7. In Section E, describe your coverage request in detail. Attach supporting documents as needed.
8. Finally, mail or fax the completed form to Express Scripts at the provided address or fax number.

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