To submit a Medicare Part D Drug Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies section on this page.
Continuous Glucose Monitors and Supplies
To submit a Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitors and Supplies section on this page.
Medicare Part B Medical Drugs
Medicare Part B Medical Drugs may require a Prior Authorization depending on the drug.
Sentara Medicare Part B Preferred Step Therapy Drug List
Sentara Medicare Part B Drug Policy Criteria
To submit a request for a Part B Medication that requires Prior Authorization, please Fax the Medication Precertification Request form:
Form can be submitted to:
Sentara Health Plans
Fax: 1-844-895-3232
Sentara Medicare Medical Medication Precertification Request
If you do not find your drug on either the links list above under Medicare Part B section, click here to access the Prior Authorization Lookup Tool (PAL) to verify if the drug requires a Prior Authorization.
Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies
A coverage determination is a decision made by our plan (not the pharmacy) about your Part D prescription drug benefits. To ask for a coverage determination, fill out the Coverage Determination Form.
Medicare HMO Drug Coverage Determination Form (Spanish)
Coverage Determination forms can be submitted to:
Express Scripts
Attn: Medicare Reviews
PO Box 66571
St. Louis, MO 63166-6571
Fax: 877-251-5896
You can also request a coverage determination through electronic PA. Click here for more information on how to submit a Medicare Coverage Determination through electronic method.
Pharmacy Redetermination or Part D drug Appeal
If Sentara Health Plans denies a request for Medicare prescription drug coverage, you may request a redetermination or appeal. To initiate a redetermination, download and fax in the Redetermination Forms.
Medicare HMO Drug Redetermination Form (Spanish)
Redetermination forms can be submitted to:
Express Scripts, Inc.
Attn: Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Fax: 877-852-4070
You can also initiate a redetermination request through electronic PA. Click here for more information on how to submit a Medicare Coverage Determination through electronic method.