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.

QuestionAnswer
Form NameExpress Scripts Androgel
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesexpress scripts tier exception, express scripts medicare tier exception form, expressscript, express scripts tier exception form

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.

Additionalformsavailable:www.express-scripts.com/pa

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:

State:

 

Zip Code:

Diagnosis:

ICD Code:

 

 

 

 

 

Please indicate which drug and strength is being requested:

 

 

QuantityRequested

for

dayssupply

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

PrescriberSignature:

 

 

 

Date:

 

 

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 quantity limit exception form cancer medication

In the Please indicate which drug and, QuantityRequested, for, days supply, Other MedicationsTherapies tried, Prescriber Signature, Office Contact Name, Date, Phone Number, and Based upon each patients area, note your information.

express scripts quantity limit exception form cancer medication Please indicate which drug and, QuantityRequested, for, days supply, Other MedicationsTherapies tried, Prescriber Signature, Office Contact Name, Date, Phone Number, and Based upon each patients blanks to complete

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