Express Scripts Form PDF Details

Express Scripts, a third-party pharmacy benefits manager, has announced a new form that drug manufacturers must complete in order to have their products covered by Express Scripts. This form, which will be effective as of January 1, 2019, requests extensive information about the product, including its formulation and active ingredients. Drug manufacturers that do not submit this information may have their products removed from the Express Scripts formulary.

You can find more details concerning the express scripts form by looking through the listing our team put together.

QuestionAnswer
Form NameExpress Scripts Form
Form Length1 pages
Fillable?Yes
Fillable fields32
Avg. time to fill out6 min 39 sec
Other namesexpress scripts refill form, express scripts online forms, express scripts mail order form printable, express scripts form printable

Form Preview Example

_...

-"EXPRESS SCRIPTS'

~. ORDER FORM FROM EXPRESS SCRIPTS

FAX TO: 800-396-2171

It can take up to 72 hours for the prescription to be entered into our system after your fax is received. It is not necessary to resend the prescription or to call the prescription into our Service Center. Doing so will only delay the fulfillment of your patient's order. Only a prescriber's office may submit fax prescriptions. CII prescriptions CANNOT be faxed.

For future orders you must use this form to fax orders to ExpressScripts.

1. Fill in ALL of the information below.

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Q! u

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c

Dr/Prescriber Name:

DEAor NPI #:

Address, City, State, Zip:

 

 

Phone:

Fax:

Mid-Level Practitioner's Supervising Physidan Name:

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1-4

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0.

Patient Name:

Plan 10:

Phone:

Date of Birth:

Address, City, State, Zip:

Rx Form (ONE Fax Form per Patient)

Date:

In order for a brand name product to be dispensed, the prescriber MUST handwrite 'BRAND NECESSARY' or 'BRAND MEDICALLY NECESSARY' in the table below.

DrugNcme

Strength

Qly

Directions For Use

RefiDs

Brand Necessary I Brand Medically Necessary

1

2

3

 

 

Dr/Prescriber

Printed

Name

 

 

 

 

 

 

 

 

Dr/Prescriber

 

Signature

- SUbstitution

Permissible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l",pa1ant

Confidentially

I«:ti::e; This and any

docurrents ao:anpanyilg

this t",nsmissbn

may

coolain rooMential health

irfumatbn

that

~ "'Jilly

pr.viege<J. Th~ ilfonnation

is nlffid€d 0'!1y

fo- tlle US<' D tl;e

iroi\ld""l

elf entily

named

"beNe

The ilUtlni2ed re::ipient d this infonmlim is prohibited from disf:.ta;i"'l this

nformolioo

In

ony

ctl\er

party unless requred to do so

by tNl

C<reg_ion.

If '1<:<1 "'" net

It\e

intended

recipient,

you

are

Ilereby

notfied

that

ony dsclosure,

<DP'ling,

distributioo,

 

OF

adi<:n

taken in relance

O'! the rontel1ts

of these

dCOJmenrs

~ stri<lly pro/libited.

If you

have received

!!lis i"lfomlatJon

 

n

error, please notify

the

sender illllled iately

and

"rr""ge fur the

retu", or de>trueticn

of these docurrerts.

 

 

 

 

 

 

 

 

 

 

 

 

 

©2007 Express SCripts, Inc.

Fax ConfirmationForm

TEMFAXREPlYFRMRev 08/23/2007

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You will need to type in the following information so that you prepare the document:

express scripts online forms blanks to fill in

Put down the information in the DrPrescriber, PrintedName, DrPrescriber, SignatureSUbstitution, Permissible, lpaantConfidentially, ItieThisandanydocurrents, aoanpanyilg, thistnsmissbn, maycoolainrooMential, healthirfumatbn, iroildl, elfentilynamedbeNeTheilUtlnied, thisnformolioo, and Inonyctlerpartyunless field.

step 2 to entering details in express scripts online forms

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