Benefit Coverage Request Form 2025

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How to Request a Coverage Determination. An enrollee, an enrollees prescriber, or an enrollees representative may request a standard or expedited coverage determination by filing a request with the plan sponsor. Standard or expedited requests for benefits may be made verbally or in writing.
A coverage determination/organization determination is a decision we make about your benefits. This can be a decision about how we cover a drug or how much you pay for the drug. A coverage determination/organization determination is also referred to as an initial determination.
If a coverage review is required, your pharmacy will receive an alert. This means that more information is needed from your doctor to see if your plan covers the medication. Ask your doctor to either call Express Scripts to request a coverage review or to prescribe an alternative medication thats covered by your plan.
Prior authorization may also be referred to as coverage determination, as under Medicare Part D.
A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount youll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.