Express Scripts Prior Authorization – Fill Out and Use This PDF

Updated: Nov 9, 2026

The Express Scripts Prior Authorization form is a crucial document for any plan member prescribed medication requiring prior authorization. This form, which must be completed and submitted by the plan member, involves a meticulous review process by Express Scripts Canada based on pre-defined clinical criteria to determine the eligibility for drug reimbursement through the private drug benefit plan. For a smooth and efficient experience in completing your Express Scripts Prior Authorization form, click the button below.

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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.

Question	Answer
Form Name	Express Scripts Prior Authorization
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	express scripts prior authorization form, express scripts prior authorization, express scripts pa form pdf, esrx pa com

How to Fill Out Request for Prior Authorization

Request for Prior Authorization at a glance

What it is: Request for Prior Authorization: Complete and Submit Your Request.

Who signs: Sign on the line for Plan Member Signature and enter the Date. Sign on the line for Physician Signature and enter the Date.

Any plan member who is prescribed a medication that requires prior authorization needs to complete and submit this form.

A filled-in Request for Prior Authorization example: a plan member fills out Part A

Request for Prior Authorization example filled out, example: a plan member fills out Part A — Dana Sample, a plan member, fills out Part A of the request. Is the patient enrolled in any patient support program? No, so Contact name and Telephone stay empty. The picture shows page 2 without its check boxes (Relationship, Language, Gender, Yes or No), and every value in it is made up.

How to fill out Request for Prior Authorization, box by box

Patient information

In Part A, enter First Name, Last Name, Insurance Carrier Name/Number, Group number, Client ID and Date of Birth (DD/MM/YYYY).

Relationship: Employee, Spouse or Dependent. Language: English or French. Gender: Male or Female.

Address, email and telephone

Enter Address, City, Province, Postal Code, Email address, Telephone (home), Telephone (cell) and Telephone (work).

Patient Assistance Program

Patient Assistance Program: Is the patient enrolled in any patient support program? Yes or No. Enter the Contact name and Telephone.

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.

Sign on the line for Plan Member Signature and enter the Date.

More rules for Request for Prior Authorization

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 plan member will be notified whether their request has been approved or denied.

You have the right to appeal the decision made by Express Scripts Canada.

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).

All information requested in Part B - Prescribing Doctor 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 Authorization Renewal for this drug: Fill sections 1, 3 and 4.

Part B - Prescribing Doctor

Section 1 - Drug requested

Under SECTION 1 - DRUG REQUESTED, enter Drug name, Dose, Administration (ex: oral, IV, etc), Frequency, Duration and Medical condition.

Will this drug be used according to its Health Canada approved indication(s)? Yes or No.

Site of drug administration: Home, Doctor office/Infusion clinic, Hospital (outpatient) or Hospital (inpatient).

Section 2 - First-time application

Under SECTION 2 - FIRST-TIME APPLICATION, enter 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)

Enter the therapies (pharmacological/non-pharmacological) that will be used for treating the same condition concomitantly.

Section 2 - Continued, previously tried therapies

Under Section 2 - Continued, list previously tried therapies: Drug, Dosage and administration, Duration of therapy From and To, and Reason for cessation: Inadequate/ Suboptimal response or Allergy/ Drug Intolerance.

Section 3 - Renewal information

Under SECTION 3 - RENEWAL INFORMATION, enter the Date of treatment initiation and the Details on clinical response to requested drug. Example: PASI/BASDAI, laboratory tests, etc. 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

Under SECTION 4 - PRESCRIBER INFORMATION, enter Physician's Name, Address, Tel, Fax, License No. and Specialty.

Sign on the line for Physician Signature and enter the Date.

Common questions about Request for Prior Authorization

What is the Express Scripts prior authorization process?

Plan Member completes Part A. Prescribing doctor completes Part B.

Where do I file it?

Fax or mail the completed form to Express Scripts Canada. Fax: Express Scripts Canada Clinical Services 1 (855) 712-6329. Mail: Express Scripts Canada Clinical Services 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5.

Sources

[1] Request for Prior Authorization, Express Scripts Canada (the Official source link on this page).