Get - Express Scripts

Filling out the Express Scripts prior authorization form is essential for ensuring that patients receive the necessary medications in a timely manner. This guide provides clear, step-by-step instructions to help you accurately complete the form online and submit it efficiently.

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

1. Press the ‘Get Form’ button to access the prior authorization form. This will allow you to open the document for filling out.
2. Begin by providing patient information. Fill in the patient’s first name, last name, date of birth, patient ID number, and phone number in the designated fields.
3. Next, enter the prescriber’s information. Include the prescriber’s name, DEA/NPI number, phone number, fax number, and address.
4. Indicate the patient's primary diagnosis and the corresponding ICD code in the provided sections.
5. Specify which medication is being requested from the list provided, ensuring to select the correct strength. Tick the appropriate box next to the chosen drug.
6. Provide directions for use, including dosage frequency (e.g. once daily, twice daily), and quantity to be prescribed in the designated area.
7. Complete the clinical assessment section by answering the questions regarding the patient's current medication usage and history. This includes details about previous medications tried and any relevant additional information.
8. Add any additional comments, symptoms, or important information that may assist in the approval of the prior authorization.
9. Obtain the prescriber’s signature and date the form appropriately. Additionally, fill in the office contact name and phone number for follow-up.
10. Once all sections are completed, review the form for accuracy before proceeding to save any changes. You can then download, print, or share the document as needed.

Complete your document online to ensure timely processing of prior authorization requests.