Express Scripts Androgel – Fill Out and Use This PDF

Express Scripts Androgel is a prescription drug used for treating male hypogonadism. It works by replacing testosterone in the body and helps to improve muscle mass, bone density, and fat distribution.

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Express Scripts Androgel PDF Details

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Question	Answer
Form Name	Express Scripts Androgel
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	express scripts tier exception, express scripts medicare tier exception form, expressscript, express scripts tier exception form

12

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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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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.

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