Get Express Scripts Lepg427 2016-2025

Filling out the Express Scripts LEPG427 form is an essential step in requesting coverage for prescription medications beyond your health plan's standard offerings. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Benefit Coverage Request Form.

1. Press the ‘Get Form’ button to obtain the form and open it for completion.
2. In Section A, enter your Member I.D. Number and indicate if the coverage request is for a Medicare Prescription Drug Plan claim by checking the appropriate box.
3. Enter the patient’s first name, middle initial, last name, and full address.
4. Indicate the patient's gender by selecting either the 'Male' or 'Female' option.
5. Input the patient's date of birth in the field labeled 'D.O.B.'
6. Specify the relationship of the patient to the cardholder by checking one of the following options: Member, Spouse, Child, or Other.
7. In Section B, identify who is making the coverage request. If an appointed representative is acting on behalf of the patient under a Medicare Prescription Drug Plan, submit form CMS 1696 alongside this document.
8. In Section C, provide the medication information, detailing the drug name, strength, dosage form, quantity, amount taken per day, and the relevant date(s) of service for each medication. If more space is needed, attach an additional page.
9. In Section D, enter the prescribing physician's name, address, city, state, zip code, and their National Provider Identifier (NPI). Additionally, include the physician’s telephone number with area code.
10. In Section E, accurately describe your coverage request in detail. If the provided space is insufficient, you may attach additional pages to include comprehensive information regarding your health condition or circumstances.
11. Ensure you include any necessary receipts for reimbursement requests and additional supporting documentation from the physician, if applicable.
12. After completing all sections of the form, review your entries for accuracy. You can choose to save your changes, download a copy, print the form, or share it as needed.

Complete the Express Scripts LEPG427 form online to ensure your medication coverage review is processed efficiently.