Get Express Scripts Printable Prior Authorization Form

The Express Scripts Printable Prior Authorization Form is essential for obtaining medication approval, particularly for specialty drugs like . Filling out this form correctly ensures a smooth authorization process.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to download and access the Express Scripts Printable Prior Authorization Form.
2. Begin by entering the patient's personal details including their last name, first name, date of birth, and home address. Ensure accuracy to avoid processing delays.
3. Input the prescriber’s information: name, specialty, and contact numbers. This section is crucial for follow-up communications.
4. Fill in the medication details, including the name of the medication (), diagnosis, dosage instructions (sig), quantity, and refills. Include ICD 9 code if applicable.
5. Specify if the diagnosis is for treating relapsing forms of Multiple Sclerosis. You must select 'Yes' or 'No' for clarity on medical necessity.
6. Indicate if is prescribed by a neurologist and if the patient has previously used or .
7. Respond to health risk questions regarding bradyarrhythmia and provide relevant test results if required, including baseline ECG and recent CBC and liver enzyme tests.
8. Include any additional comments, diagnoses, or relevant lab values that might assist in the authorization review.
9. Sign the form as the physician and enter the NPI/DEA number, along with the date of signature to complete the authorization request.
10. Once all sections are thoroughly completed, save any changes made to the form. You may download, print, or share the completed form as necessary for submission.

Complete your prior authorization form online today for a quicker approval process.