Request a Medical Exception
What to do if a drug is not covered
If your prescription is not listed in the List of Covered Drugs or is restricted, please contact Member Services to confirm that your desired drug is not covered. Our List of Covered Drugs is updated regularly and this could save you extra steps.
If Member Services confirms that your drug is not covered, you can change to another drug or ask for an exception. Start by talking with your provider to determine if another drug is available to you that might work just as well. Member Services can share a list of covered drugs that treat the same medical condition you have. This list can help your provider find a covered drug that might work for you.
New members can receive drugs not listed on the List of Covered Drugs for a short time
You may be eligible to receive an initial transition supply of a drug anytime during the first 90 days you are a plan member. This will give you time to talk to your doctor and find a good alternative that is covered by our plan. Learn more about drug coverage for new members.
Request that a drug is covered
It is your right to request that we cover a drug that we do not typically cover or cover a drug that has restrictions. Your provider can help you request a coverage decision, also called a coverage determination, and provide reasons why you need the drug.
How do I request a coverage decision?
You, your doctor, or an appointed representative can request a coverage decision on your behalf.
Please complete the Model Drug Coverage Determination Form (Medicaid + Medicare) or the Model Drug Coverage Determination Form (Medicaid Only) and submit it to us one of the following ways:
- Mail to:
P.O. Box 66588
St. Louis, MO 63166-6588
Attn: Medicaid Reviews
- Fax to: 1-877-251-5896
- Call Express Scripts: 1-877-417-1828
What happens next?
We will review your request and then make a coverage determination, which is a decision about whether we will cover the drug you requested and the amount, if any, that you are required to pay for the drug. We will notify you of our decision within 72 hours from when we received your request. If your doctor agrees that waiting 72 hours will harm your health, you or your doctor can ask us for a faster decision. If you submit the request, your doctor must also call or write us to confirm the need. We will then give a decision within 24 hours.
If your request is not approved, you have the right to appeal our decision.
Related Forms and Policies
- To appeal a coverage decision - Use the Request for Redetermination of Medicare Prescription Drug Denial Form
- Best Available Evidence Policy - If your income changes and you lose your Medicaid status, you may be responsible for some of your health care costs. Learn how your costs are determined.