Get Express Scripts Coverage Determination Form

Filling out the Express Scripts Coverage Determination Form online can be a straightforward process with the right guidance. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your selected editor.
2. Begin by filling in the enrollee’s information. This includes the enrollee’s name, date of birth, address, city, state, phone number, member ID, and zip code. Ensure all information provided is accurate.
3. If the requestor is not the enrollee or prescriber, complete the requestor’s section with their name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. If applicable, attach documentation that proves the requestor’s authority to represent the enrollee. This could be an Authorization of Representation Form CMS-1696 or a similar written document.
5. Indicate the name of the prescribed drug you are requesting, including its strength and the quantity desired per month if known.
6. Select the type of coverage determination request that applies to your situation, such as a formulary exception or prior authorization. Make sure to review each option carefully.
7. If there is additional information to support your request, attach any relevant supporting documents to provide context.
8. If you believe that waiting 72 hours for a standard decision may harm your health, indicate this by checking the appropriate box for an expedited review.
9. Have the prescriber complete their information in the provided section, which includes their name, address, office phone number, fax number, and signature.
10. Fill in the medical information section, detailing the medication, strength, route of administration, diagnosis, and rationale for the request. Be specific about any adverse outcomes from previous medications.
11. Once you have completed all sections, save your changes, download the form, print it, or share it as needed.

Start completing your Express Scripts Coverage Determination Form online today!