Express Scripts Pa Details

Express Scripts has a Prior Authorization Form that you will need to fill out in order to get your medication prescribed. This form is used to ensure that patients are getting the medications they need and that the medications are being used for their intended purpose. It can be helpful to have an idea of what information you will need before you start filling out the form. This blog post will provide an overview of what information is needed on the Express Scripts Prior Authorization Form, as well as some tips on how to complete it.

Here is the data about the form you were seeking to fill out. It will tell you how much time you will need to finish express scripts prior authorization, what parts you need to fill in and several other specific facts.

Form NameExpress Scripts Prior Authorization
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesexpressscr, esrx pa com, 800 417 8164, express scripts pa form

Form Preview Example

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.

Additional forms available:

Prior Authorization Form

Sedative Hypnotic Step Therapy

Fax completed form to 1-800-357-9577

If this 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: __________________

Primary Diagnosis: _________________________________ ICD Code: ________________________________________

Please indicate which drug and strength is being requested:

Ambien 5mg

Intermezzo 1.75 mg Sublingual Tablet

Silenor 3mg

Ambien 10mg

Intermezzo 3.5 mg Sublingual Tablet

Silenor 6mg

Ambien CR 6.25mg

Lunesta 1mg

Sonata 5mg

Ambien CR 12.5mg

Lunesta 2mg

Sonata 10mg

Edluar 5mg Sublingual Tablet

Lunesta 3mg

Zolpimist 5mg/actuation Oral Spray

Edluar 10mg Sublingual Tablet

Rozerem 8mg



Directions for use (i.e. QD, BID, PRN & Qty):__________________________________________________________________________

Please complete the clinical assessment:


Is the patient currently taking the requested medication?





If yes, for how long? _______________________________________________________





Is the patient taking samples or paying 100% out of pocket for the medication being










If no, please indicate:





Requested medication covered under previous insurance plan





Started medication in hospital




















Does the patient have difficulty swallowing OR is the patient unable to swallow tablets?










Does the patient have a documented history of addiction to controlled substances?









5.Does the patient have middle-of-the-night awakening followed by difficulty returning to sleep?

6.Has the patient tried zolpidem IR, zolpidem ER, or zaleplon?

If yes, please indicate which sedative hypnotic patient has tried: ____________________








Are there any other comments, diagnoses, symptoms, and/or any other information the physician feels is important to this review?









Prescriber Signature: __________________________________________Date: ____________________

Office Contact Name: ___________________________ Phone Number: __________________________

Based upon ea h patie t’s p es iptio pla , additio al uestio s ay e e ui ed to o plete the p io autho izatio p o ess. 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, or 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.

Sedative Hypnotics Step Therapy


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