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Request for Medicare Drug Coverage Determination

How Do I Submit a Request?

Fill out the online form below or use this fillable PDF request form and mail to:

Express Scripts, Inc.
Attn: Medicare Reviews
PO Box 66571
St. Louis, MO 63166-6571

Or, you can send the form by fax to 877-251-5896. You may also ask us for a coverage determination by phone by calling 800-316-3107 (TTY 800-947-3529).

Who May Make a Request?

Your prescriber may ask for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.


Network Health
1570 Midway Place
Menasha, WI 54952
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.