Express Scripts Prior Authorization PDF Details

Navigating the realm of prescription medications can often seem like an intricate dance, especially when certain drugs require prior authorization. This is where the Express Scripts Prior Authorization form plays a critical role. Designed to streamline the process for plan members prescribed medications that necessitate an additional layer of approval, this form is a key step in ensuring patients receive the medication they need in accordance with their health insurance plan's requirements. The process is methodically divided into three straightforward steps, beginning with completion by the plan member, followed by their prescribing doctor, and culminating in the form's submission to Express Scripts Canada. However, it's pivotal to understand that filling out and submitting this form does not automatically guarantee approval. Approval is contingent upon a thorough review process, where decisions are made based on strict clinical criteria and Health Canada's approved indications for the drug. In cases where a request is denied, plan members are entitled to appeal the decision, underlining the process's transparency and the patient's right to advocate for their health needs. Notification of the approval or denial is promptly communicated, ensuring both the plan member and the prescribing doctor are informed of the outcome, thereby facilitating ongoing care and treatment planning. This form not only functions as a necessary procedural step but embodies a measure designed to ensure that drug prescriptions are justified, medically necessary, and aligned with evidence-based clinical guidelines.

QuestionAnswer
Form NameExpress Scripts Prior Authorization
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesexpress scripts prior authorization form, express scripts prior authorization, express scripts pa form pdf, esrx pa com

Form Preview Example

Request for Prior Authorization

Complete and Submit Your Request

Any plan member who is prescribed a medication that requires prior authorization needs to complete and submit this form. Any fees related to the completion of this form are the responsibility of the plan member.

3 Easy Steps

STEP 1

Plan Member completes Part A.

STEP 2

Prescribing doctor completes Part B.

STEP 3

Fax or mail the completed form to Express Scripts Canada®.

Fax:

Mail:

Express Scripts Canada Clinical Services

Express Scripts Canada Clinical Services

1 (855) 712-6329

5770 Hurontario Street, 10th Floor,

 

Mississauga, ON L5R 3G5

Review Process

Completion and submission of this form is not a guarantee of approval. Plan members will receive reimbursement for the prior authorized drug through their private drug benefit plan only if the request has been reviewed and approved by Express Scripts Canada.

The decision for approval versus denial is based on pre-defined clinical criteria, primarily based on Health Canada approved indication(s) and on supporting evidence-based clinical protocols.

Please note that you have the right to appeal the decision made by Express Scripts Canada.

Notification

The plan member will be notified whether their request has been approved or denied. The decision will also be communicated to the prescribing doctor by fax, if requested.

Please continue to page 2.

Page 1

Request for Prior Authorization

Part A – Patient

Please complete this section and then take the form to your doctor for completion.

Patient information

 

 

 

 

 

 

First Name:

 

 

 

Last Name:

 

 

Insurance Carrier Name/Number:

 

 

 

 

 

Group number:

 

 

 

Client ID:

 

 

Date of Birth (DD/MM/YYYY):

/

/

Relationship:

□ Employee

□ Spouse □ Dependent

Language:

□ English

□

French

Gender:

□ Male

□ Female

Address:

 

 

City:

Province:

Postal Code:

Email address:

 

 

Telephone (home):

Telephone (cell):

Telephone (work):

Patient Assistance Program

 

 

Is the patient enrolled in any patient support program? ❒ Yes

❒ No

Contact name:

Telephone:

Provincial Coverage

 

 

Has the patient applied for reimbursement under a provincial plan? ❒ Yes ❒ No

What is the coverage decision of the drug? ❒ Approved ❒ Denied **Attach provincial decision letter**

Primary Coverage

If patient has coverage with a primary plan, has a reimbursement request been submitted? ❒ Yes ❒ No ❒ N/A What is the coverage decision of the drug? ❒ Approved ❒ Denied **Attach decision letter **

Authorization

On behalf of myself and my eligible dependents, I authorize my group benefit provider, and its agents, to exchange the personal information contained on this form. I give my consent on the understanding that the information will be used solely for purposes of administration and management of my group benefit plan. This consent shall continue so long as my dependents and I are covered by, or are claiming benefits under the present group contract, or any modification, renewal, or reinstatement thereof.

Plan Member Signature

Date

Page 2

Request for Prior Authorization

Part B – Prescribing Doctor

Drugs in the Prior Authorization Program may be eligible for reimbursement only if the patient uses the drug(s) for Health Canada approved indication(s). Please provide information on your patient's medical condition and drug history, as required by the group benefit provider to reimburse this medication.

All information requested below is mandatory for the approval process, any fields left blank will result in an automatic denial. Please fill any non-applicable fields with ‘N/A’. Supplemental information for this drug reimbursement request will be accepted.

❒First time Prior Authorization application for this drug *Fill sections 1, 2 and 4*

❒Prior AuthorizationRenewal for this drug *Fill sections 1, 3 and 4*

SECTION 1 – DRUG REQUESTED

Drug name:

Dose Administration (ex: oral, IV, etc) FrequencyDuration

Medical condition:

Will this drug be used according to its Health Canada approved indication(s)?

❒ Yes ❒ No

Site of drug administration:

 

❒ Home ❒ Doctor office/Infusion clinic ❒ Hospital (outpatient)

❒ Hospital (inpatient)

SECTION 2 – FIRST-TIME APPLICATION

Any relevant information of the patient’s condition including the severity/stage/type of condition

Example: monthly frequency and duration for migraines, fibrosis status for Hepatitis C patient, lab values such as LDL and IgE levels, BMI, symptoms etc. (please do not provide genetic test information or results)

Therapies (pharmacological/non-pharmacological) that will be used for treating the same condition concomitantly:

Page 3

Request for Prior Authorization

Section 2 - Continued

Please list previously tried therapies

 

Duration of therapy

Reason for cessation

Drug

Dosage and

 

Inadequate/

Allergy/

 

administration

 

 

From

To

Suboptimal

Drug

 

response

Intolerance

 

 

 

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

SECTION 3 – RENEWAL INFORMATION

Date of treatment initiation:

Details on clinical response to requested drug

Example: PASI/BASDAI, laboratory tests, etc. (please do not provide genetic test information or results)

If prior approval was not authorized by Express Script Canada, please attach a copy of the approval letter.

SECTION 4 – PRESCRIBER INFORMATION

Physician’s Name:

 

Address:

 

Tel:

Fax:

License No.:

Specialty:

Physician Signature:

Date:

Page 4

How to Edit Express Scripts Prior Authorization Online for Free

The express scripts prior auth filling in procedure is simple. Our PDF tool allows you to work with any PDF form.

Step 1: The initial step would be to select the orange "Get Form Now" button.

Step 2: Now it's easy to modify your express scripts prior auth. This multifunctional toolbar lets you insert, remove, change, and highlight text or perhaps perform other sorts of commands.

For every single part, create the details requested by the application.

express scripts pa form spaces to fill in

The program will require you to fill in the Has the patient applied for, Yes, What is the coverage decision of, Approved, Denied Attach provincial decision, Primary Coverage, If patient has coverage with a, Yes, What is the coverage decision of, Approved, Denied Attach decision letter, Authorization, On behalf of myself and my, Plan Member Signature, and Date section.

Completing express scripts pa form step 2

The system will ask you to put down some important info to instantly submit the segment First time Prior Authorization, Prior Authorization Renewal for, SECTION DRUG REQUESTED, Drug name, Dose, Administration ex oral IV etc, Frequency, Duration, Medical condition, Will this drug be used according, Yes, Site of drug administration, Home, Doctor officeInfusion clinic, and Hospital outpatient.

express scripts pa form First time Prior Authorization, Prior Authorization Renewal for, SECTION DRUG REQUESTED, Drug name, Dose, Administration ex oral IV etc, Frequency, Duration, Medical condition, Will this drug be used according, Yes, Site of drug administration, Home, Doctor officeInfusion clinic, and Hospital outpatient fields to fill out

You will need to indicate the rights and responsibilities of each party in paragraph Any relevant information of the, Therapies, and Page.

stage 4 to filling out express scripts pa form

End up by analyzing the next fields and filling them in as required: From, Inadequate Suboptimal response, Allergy Drug Intolerance, SECTION RENEWAL INFORMATION, Date of treatment initiation, Details on clinical response to, and Example PASIBASDAI laboratory.

From, Inadequate Suboptimal response, Allergy Drug Intolerance, SECTION RENEWAL INFORMATION, Date of treatment initiation, Details on clinical response to, and Example PASIBASDAI laboratory in express scripts pa form

Step 3: After you select the Done button, your ready document can be transferred to any of your gadgets or to electronic mail indicated by you.

Step 4: In order to avoid potential future risks, it is important to have around two or three duplicates of any document.

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