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Er) should contact Express Scripts, Inc (ESI):  You may Call ESI at 1-844-424-8886, 24 hours a day, 7 days a week, TTY users: 1-800-716-3231  You may Fax your request to: 1-877-251-5896 (Attention: Medicare Reviews)  You may also send your request via email to: medicarepartdparequests@express-scripts.com Member’s Last Name: Member’s First Name: SCAN ID number: Date of Birth: Prescriber’s Name: Contact Person: Office phone: Office Fax: Medication: Diagnosis: SECTION A Pl.

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