Appeals and Grievances

If you disagree with the decision on your pharmacy claim (e.g., if your claim is denied), or if your request for medical necessity or prior authorization is denied, you may file an appeal, or if you have a complaint with the quality services you received from a network or the mail order pharmacy, you may submit a grievance.

Filing an Appeal
The request (or appeal) for reconsideration of your pharmacy claim, medical necessity or prior authorization decision must be in writing, signed, and postmarked or received by Express Scripts within 90 calendar days from the date of the decision, and must include a copy of the claim decision.

Your signed written request must state the specific matter with which you disagree and must be sent to the following address no later than 90 days from the date of the notice:

Express Scripts, Inc.
P.O. Box 60903
Phoenix, AZ 85082-0903

Additional documentation in support of the appeal may be submitted; however, because the request for reconsideration must be postmarked or received within 90 calendar days from the date of the decision, the request for reconsideration should not be delayed pending the acquisition of additional documentation. If additional documentation will be submitted at a later date, the letter requesting the reconsideration must include a statement that additional documentation will be submitted and the expected date of the submission. Upon receiving your request, all decisions related to the entire course of treatment will be reviewed.

Submitting a Grievance
A grievance is a written complaint or concern about a non-appealable issue regarding a perceived failure by any member of the pharmacy team. The grievance process allows you the opportunity to report in writing any concern or complaint regarding your health care quality or service. All grievances about a pharmacy provider, such as a network pharmacy, go directly to Express Scripts in one of the following ways: