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  • Express Scripts Prior Authorization Form

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Tact (Name) Home Address City State ZIP Address City State ZIP Shipping Address (if different from home address) Physician Home Phone Number SCAN ID number Special Instructions (i.e. Non-English Speaking Patient, etc.) Date of Birth Complete Prescription Information Before Faxing Medication: Sig: Fax Number Statement of Medical Necessity Primary Diagnosis:.

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Express Scripts' prior authorization phone lines are open 24 hours a day, seven days a week, so a determination can be made right away. If the information provided meets your plan's requirements, you pay the plan's copayment at the pharmacy.

Certain prescription medications need to be preapproved by Express Scripts before they will be covered. This preapproval process is known as prior authorization. If you do not receive approval for drugs requiring prior authorization, you may pay the full cost of the medication.

To get started, grab your Express Scripts ID card and visit .express-scripts.com. If you have questions, please call Express Scripts toll-free at 866‑685‑2792 (non-Medicare enrollees) or 888‑416‑3326 (Medicare enrollees).

Tell us a little about your needs or challenges and let's start the conversation. For help with your prescription benefit or prescriptions filled through the Express Scripts Pharmacy, call Patient Customer Service at the number on your prescription ID card or call 800.282. 2881.

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

If your prescription requires prior authorization, you or your doctor can initiate the prior authorization review by calling Express Scripts at 1-800-753-2851.

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

Protect your personal information: Express Scripts may need to reach out to you by either call or email to clarify your prescription information for order processing or alert you about an unpaid balance.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232