Get Express Scripts

This guide provides clear, step-by-step instructions for filling out the Express Scripts prior authorization form for . By following these directions, you will ensure all necessary information is provided accurately for a successful submission.

Follow the steps to complete the Express Scripts prior authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the patient information section. This includes the patient's first name, last name, date of birth, phone number, and ID number. Be sure to provide accurate information to avoid processing delays.
3. Next, complete the prescriber information section. Provide the prescriber's name, DEA/NPI number (required), phone number, fax number, and address, ensuring that all details are correct.
4. In the primary diagnosis section, indicate the diagnosis by providing the diagnosis name and corresponding ICD code.
5. Specify which drug and strength is being requested by checking the appropriate box among the options provided.
6. Detail the directions for use, including the dosage frequency and quantity.
7. Proceed to the clinical assessment section. Answer each question with 'Yes' or 'No', adding any necessary explanations where prompted.
8. Conclude by filling in any additional comments or relevant information that may assist in the review process.
9. Finally, ensure the prescriber signature is included, along with the date of completion. Review all information for accuracy before finalizing.
10. Once all sections are complete, save your changes. You may choose to download, print, or share the completed form as needed.

Complete the Express Scripts prior authorization form online to ensure your request is processed smoothly.