Get Express Scripts Prior Authorization Form

The Express Scripts Prior Authorization Form is a crucial document used to request permission for specific medications. This guide will help you navigate each section of the form, ensuring that you provide all necessary information for a successful request.

Follow the steps to accurately fill out the form online.

1. Click the ‘Get Form’ button to access the online form and open it in the editing interface.
2. Fill in the patient information section, including the first and last name, date of birth, and patient ID number. Ensure all details are accurate for proper identification.
3. Complete the prescriber information section. This includes the prescriber's name, DEA/NPI number, phone, and fax numbers, as well as the prescriber’s address, state, and zip code.
4. Input the diagnosis and relevant ICD code. This information aids in evaluating the appropriateness of the requested medication.
5. Indicate the specific drug and strength being requested. Provide the quantity requested and the number of days' supply needed.
6. Detail any other medications or therapies that have been tried along with reasons for their failure. Include any additional information that supports the request.
7. Have the prescriber sign and date the form. Ensure the office contact name and phone number are filled in for follow-up communication.
8. Review all provided information for accuracy and completeness. Once confident, you can save changes, download, print, or share the form as necessary.

Take action today and complete your forms online to ensure a smoother authorization process.