Express Scripts Prior Authorization PDF Form - FormsPal

Express Scripts Prior Authorization PDF 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.

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

12

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		Inadequate/	Allergy/
	From	To	Suboptimal	Drug
	From	To	response	Intolerance
			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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