Pharmacy forms and resources

Prescription drug coverage request forms

• Request for Medicare Prescription Drug Coverage Determination form
• Request for Redetermination of Medicare Prescription Drug Denial
• Appointment of Representative form
• Pharmacy Reimbursement Form

To file a grievance.

1. Name a doctor, lawyer or family member as you Representative.
2. Fill out the form.
3. Mail to:

Express Scripts
P.O. Box 3610
Dublin, OH 43016-0307

For help, call (888) 654-0706 (TTY: 711). Call seven days a week. Call from 8 a.m. to 8 p.m.

Best available evidence 

CMS made the BAE policy in 2006.

Sponsors must set up true cost-sharing. It’s for low-income recipients. It’s when facts are not right.

Federal regulations at 42 CFR § 423.800 have requirements. They’re for Part D sponsors in the management of the low-income subsidy program. It has cutting cost sharing for subsidy-eligible people.

CMS may not show the right low-income subsidy status.

For more information, see the CMS website.