Get Express Scripts Prior Authorization Form

Completing the Express Scripts Prior Authorization Form online can streamline the process of obtaining approval for necessary medications. This guide offers clear, step-by-step instructions to help users efficiently navigate the form and ensure all required information is accurately provided.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. Fill in the patient information section, including the patient's first and last name, date of birth, phone number, and patient ID number.
3. Enter the prescriber information. This includes the prescriber's name, DEA/NPI number, phone number, fax number, and address including state and zip code.
4. Indicate the primary diagnosis and the corresponding ICD code that applies to the patient's condition.
5. Select the requested medication and strength from the provided list. Ensure that you check the appropriate box for the chosen option.
6. Provide directions for use, specifying the dosage and frequency (e.g., QD, BID, PRN) for the medication.
7. Complete the clinical assessment section by answering the questions regarding the patient's previous use of the medication, their current insurance situation, and any potential drug interactions.
8. List any generic SSRIs the patient has previously tried by checking the appropriate boxes.
9. In the comments section, include any additional information relevant to the patient's case or clinical situation.
10. Sign and date the form, and include the office contact name and phone number if required.
11. Finally, save changes to the form. You may also download, print, or share the completed form as necessary.

Complete your prior authorization request online today for a smoother medication approval process.