Get Express Scripts Prior Authorization Form

Filling out the Express Scripts Prior Authorization Form online is essential for ensuring that medication requests are processed efficiently. This guide will help you navigate through each section of the form with clarity and confidence.

Follow the steps to complete the form smoothly.

1. Press the ‘Get Form’ button to access the Express Scripts Prior Authorization Form and open it for editing.
2. Begin by entering the patient's last name and first name in the appropriate fields, followed by today’s date and the date when the medication is needed.
3. Complete the contact details, including the home and work phone numbers, and the prescriber's name, as well as the office contact person’s name.
4. Fill in the home address, including the city, state, and ZIP code. If there is a different shipping address, provide that information as well.
5. Enter the physician's home phone number and the SCAN ID number in the designated fields.
6. Include any special instructions that may be relevant, such as if the patient speaks a non-English language.
7. Input the patient's date of birth to ensure accurate identification.
8. Provide complete prescription information, including the medication name and specific instructions (Sig).
9. Indicate the fax number where the form should be sent.
10. Document the primary diagnosis and corresponding ICD 9 code to support the medical necessity of the prescribed medication.
11. List the prescription quantity, dosing information, and any required refills for an extended period.
12. Specify the estimated start of therapy based on the prescription needs.
13. Fill in the primary insurance company details, including the phone number, name of the insured, ID number, and group number.
14. If applicable, provide secondary/supplemental insurance information in the same manner as the primary insurance.
15. Add any pertinent comments, diagnoses, symptoms, laboratory values, or additional relevant information that could assist in the review.
16. The physician must then sign the form, providing the UPIN/DEA number and state license number to validate the prescription.
17. Review the form to ensure all required fields are filled out completely. Finally, you may save your changes, download, or print the form for submission.

Complete the Express Scripts Prior Authorization Form online for efficient processing of your medication requests.