Express Scripts Androgel PDF Details

This general guide will let you establish just how long it'll require you to fill out express scripts androgel, how many pages it has, and some additional specific details about the PDF.

Form NameExpress Scripts Androgel
Form Length1 pages
Fillable fields27
Avg. time to fill out5 min 39 sec
Other namesexpress scripts prior authorization form testosterone, express scripts tier exception forms, expressscript, express scripts tier exception form pdf

Form Preview Example

Prior Authorization Form

General Request Form

This form is based on Express Scripts standard criteria and may not be applicable to all patients; certain plans and situations may require additional information beyond what is specifically requested.

Fax completed form to 1-877-251-5896

If this is an URGENT request, please call 1-800-417-8164

Patient Information

Patient First Name:

Patient Last Name:

Patient ID#:

Patient DOB:

Patient Phone #:



Prescriber Information

Prescriber Name:

Prescriber DEA/NPI (required):

Prescriber Phone #:

Prescriber Fax #:

Prescriber Address:



Zip Code:


ICD Code:






Please indicate which drug and strength is being requested:






Other Medications/Therapies tried and reason(s) for failure and/or any other information the physician feels is important to the review:








Office ContactName:

Phone Number:










Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.

Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions.

The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the

individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution,08.22.2011or action taken in reliance on the contents of these documents is strictly prohibited. If you received this information in error, please notify the sender

immediately and arrange for the return or destruction of the documents.

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Step 1: Look for the button "Get Form Here" on the following site and select it.

Step 2: Now, you are on the file editing page. You can add content, edit existing details, highlight particular words or phrases, place crosses or checks, add images, sign the file, erase unnecessary fields, etc.

These particular segments will compose the PDF template that you'll be creating:

portion of fields in express scripts prior authorization form medicare

In the Diagnosis, ICD, Code for, days, supply Prescribe, r, Signature and Date area, note your information.

express scripts prior authorization form medicare Diagnosis, ICDCode, for, dayssupply, PrescriberSignature, and Date blanks to complete

Note the essential particulars in Office, Contact, Name and Phone, Number field.

express scripts prior authorization form medicare OfficeContactName, and PhoneNumber blanks to insert

Step 3: Once you click the Done button, the finished file is easily exportable to any of your devices. Alternatively, you can deliver it using email.

Step 4: Make duplicates of the file - it will help you remain away from forthcoming worries. And fear not - we do not distribute or see the information you have.

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