Express Scripts Prior Authorization PDF Template

The Express Scripts Prior Authorization form is a crucial document that plan members must complete when prescribed a medication requiring prior approval. This form serves as a request for authorization, ensuring that the necessary information is gathered from both the patient and their prescribing doctor. Timely completion and submission of this form are essential for a smooth approval process, so take action now by filling out the form below.

Article Guide

The Express Scripts Prior Authorization form is a crucial document for plan members who require specific medications that necessitate prior approval. This process begins with the plan member completing Part A of the form, which collects essential personal and insurance information. Following this, the prescribing doctor must fill out Part B, providing detailed medical information and justifications for the requested medication. Once both sections are completed, the form can be submitted via fax or mail to Express Scripts Canada. It is important to note that submitting this form does not guarantee approval for the medication. The review process involves an assessment based on clinical criteria set by Health Canada and evidence-based protocols. After the review, the plan member will be notified of the decision, which will also be communicated to the prescribing doctor if requested. Should the request be denied, there is an option to appeal the decision, ensuring that plan members have a voice in the process.

Express Scripts Prior Authorization Preview

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se continue to page 2.

This document contains both information and form fields. To read

information, use the Down Arrow from a form field.

Req

uest for Prior Authorization

Complete and Submit Your Request

Any plan member who is prescribed a medication that requires prior authorization needs to complete and submit

this form. Any fees related to the completion of this form are the responsibility of the plan member.

3 Easy Steps

STEP 1

Plan Member completes Part A.

STEP 2

Prescribing doctor completes Part B.

STEP 3

Fax or mail the completed form to Express Scripts Canada

Fax:

Express Scripts Canada Clinical Services

1 (855)

712-6329

Mail:

Express Scripts Canada Clinical Services

5770 Hurontario Street, 10

Floor,

Mississauga, ON L5R 3G5

Review Process

Completion and submission of this form is not a guarantee of approval. Plan members will receive reimbursement for

the prior authorized drug through their private drug benefit plan only if the request has been reviewed and

approved by Express Scripts Canada.

The decision for approval versus denial is based on pre-defined clinical criteria, primarily based on Health Canada

approved indication(s) and on supporting evidence-based clinical protocols.

Please note that you have the right to appeal the decision made by Express Scripts Canada.

Notification

The plan member will be notified whether their request has been approved or denied. The decision will also

be communicated to the prescribing doctor by fax, if requested.

Request for Prior Authorization

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First Name: Last Name:

Insurance Carrier Name/Number:

Group number: Client ID:

□ □ □

□ □

❒ ❒

❒ ❒ ❒

❒ ❒

Date of Birth (DD/MM/YYYY): / /

Address:

Province:

Postal Code:

Email address:

Telephone (home): Telephone (cell): Telephone (work):

Contact name: Telephone:

Plan Member Signature Date

Part A – Patient

Please complete this section and then take the form to your doctor for completion.

Patient information

Relationship: Employee Spouse Dependent

Language: English French

Gender: Male Female

Patient Assistance Program

Is the patient enrolled in any patient support program? Yes No

Provincial Coverage

Has the patient applied for reimbursement under a provincial plan? Yes No

What is the coverage decision of the drug? Approved Denied **Attach provincial decision letter**

Primary Coverage

If patient has coverage with a primary plan, has a reimbursement request been submitted? Yes No N/A

What is the coverage decision of the drug? Approved Denied **Attach decision letter **

Authorization

On behalf of myself and my eligible dependents, I authorize my group benefit provider, and its agents, to exchange the

personal information contained on this form. I give my consent on the understanding that the information will be used

solely for purposes of administration and management of my group benefit plan. This consent shall continue so long as

my dependents and I are covered by, or are claiming benefits under the present group contract, or any modification,

renewal, or reinstatement thereof.

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Drug

name:

Dose

Administration (ex: oral, IV, etc) Frequency Duration

Medical condition:

❒

❒ ❒ ❒ ❒

Any

relevant information of the patient’s condition including the severity/stage/type of condition

Example: monthly frequency and duration for migraines, fibrosis status for Hepatitis C patient, lab values such as LDL

and IgE levels, BMI, symptoms etc. (please do not provide genetic test information or results)

Therap

ies (pharmacological/non-pharmacological) that will be used for treating the same condition concomitantly:

❒

Request for Prior Authorization

Part B – Prescribing Doctor

Drugs in the Prior Authorization Program may be eligible for reimbursement only if the patient uses the drug(s) for

Health Canada approved indication(s). Please provide information on your patient's medical condition and drug

history, as required by the group benefit provider to reimburse this medication.

All information requested below is mandatory for the approval process, any fields left blank will result in an

automatic denial. Please fill any non-applicable fields with ‘N/A’. Supplemental information for this drug

reimbursement request will be accepted.

First time Prior Authorization application for this drug *Fill sections 1, 2 and 4*

Prior Authorization Renewal for this drug *Fill sections 1, 3 and 4*

SECT

ION 1 – DRUG REQUESTED

Will this drug be used according to its Health Canada approved indication(s)? Yes No

Site of drug administration:

Home Doctor office/Infusion clinic Hospital (outpatient) Hospital (inpatient)

SECTION 2 – FIRST-TIME APPLICATION

Request for Prior Authorization

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Section 2 - Continued

❒ ❒

❒

Dat

e of treatment initiation:

Deta

ils on clinical response to requested drug

Example: PASI/BASDAI, laboratory tests, etc. (please do not provide genetic test information or results)

Physician’s Name:

Addres

Tel:

Fax:

cense No.: Specialty:

ysician Signature: Date:

ease list previously tried therapies

Drug Dosage and

administration

Duration of therapy Reason for cessation

From To

Inadequate/

Suboptimal

response

Allergy/

Drug

Intolerance

SECTION 3 – RENEWAL INFORMATION

f prior approval was not authorized by Express Script Canada, please attach a copy of the approval letter.

SECTION 4 – PRESCRIBER INFORMATION

↓ Express Scripts Prior Authorization

File Properties

Fact Name	Description
Purpose of the Form	This form is used by plan members to request prior authorization for medications that require it.
Responsibility for Fees	Any fees associated with completing the form are the responsibility of the plan member.
Submission Steps	Plan members must complete Part A, have their prescribing doctor complete Part B, and then submit the form via fax or mail.
Review Process	Submitting the form does not guarantee approval. Approval depends on clinical criteria set by Express Scripts Canada.
Notification of Decision	Plan members will be notified of the approval or denial of their request, and their prescribing doctor will also be informed if requested.
Right to Appeal	Plan members have the right to appeal any decision made by Express Scripts Canada regarding their request.
State-Specific Forms	For state-specific forms, the governing laws may vary, and members should refer to local regulations for guidance.

Instructions on Utilizing Express Scripts Prior Authorization

To proceed with your request for medication approval, follow these steps carefully. Completing the Express Scripts Prior Authorization form is essential for ensuring your medication is covered by your insurance plan. Make sure to provide accurate information to avoid delays.

Complete Part A: Fill out the patient information section. Include details such as your first and last name, date of birth, insurance carrier information, and contact details. Indicate if you are enrolled in any patient assistance programs and if you have applied for provincial coverage.
Consult Your Doctor: Take the completed Part A to your prescribing doctor. They will need to fill out Part B, which includes information about the medication requested and your medical condition.
Submit the Form: After both parts are completed, fax or mail the form to Express Scripts Canada. Use the fax number 1 (855) 712-6329 or send it to the address: Express Scripts Canada Clinical Services, 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5.

Once submitted, you will be notified about the approval or denial of your request. This decision will also be communicated to your prescribing doctor if requested. Remember, submitting this form does not guarantee approval, but it is a necessary step to seek reimbursement for your medication.

Important Facts about Express Scripts Prior Authorization

What is the Express Scripts Prior Authorization form?

The Express Scripts Prior Authorization form is a document that plan members must complete when prescribed a medication that requires prior approval. This form helps ensure that the medication is covered under their private drug benefit plan.

Who needs to complete the form?

Any plan member who has been prescribed a medication that requires prior authorization must complete the form. This includes providing personal information and details about the medication and medical condition.

What are the steps to complete the form?

There are three simple steps to follow: First, the plan member fills out Part A of the form. Next, the prescribing doctor completes Part B. Finally, the completed form must be faxed or mailed to Express Scripts Canada.

Is there a fee for completing the form?

Yes, any fees related to the completion of the Express Scripts Prior Authorization form are the responsibility of the plan member. It is important to be aware of this before starting the process.

What happens after I submit the form?

After submission, the request will be reviewed by Express Scripts Canada. However, completing and submitting the form does not guarantee approval. The plan member will be notified of the decision, and the prescribing doctor will also be informed if requested.

Can I appeal if my request is denied?

Yes, you have the right to appeal any decision made by Express Scripts Canada. If your request is denied, you can follow the necessary steps to contest the decision and provide additional information if needed.

What information is required in Part A of the form?

In Part A, the plan member must provide personal information such as their name, date of birth, insurance details, and contact information. Additionally, they need to indicate if they are enrolled in any patient support programs or have applied for provincial reimbursement.

What should the prescribing doctor include in Part B?

The prescribing doctor must provide detailed information about the patient's medical condition and drug history. This includes the requested drug name, dosage, administration method, and any relevant clinical information that supports the request.

How will I know if my request is approved or denied?

The plan member will receive notification regarding the approval or denial of their request. This information will also be sent to the prescribing doctor by fax if requested. Keeping track of this communication is important for further steps.

Common mistakes

Filling out the Express Scripts Prior Authorization form can be challenging. Many people make mistakes that can delay their medication approval. Here are ten common errors to avoid.

First, failing to complete all required sections is a frequent issue. Each part of the form must be filled out thoroughly. Leaving any field blank can lead to an automatic denial of the request. Make sure to provide all necessary information, even if some fields seem irrelevant.

Another mistake is not providing accurate patient information. It’s crucial to double-check the patient's name, date of birth, and insurance details. Incorrect information can cause significant delays in processing the authorization.

Many individuals also forget to attach necessary documents. If the patient has applied for reimbursement under a provincial plan, include the decision letter. This documentation is essential for the review process and can impact the outcome of the request.

Not indicating whether the request is for a first-time application or a renewal is another common oversight. Clearly marking this on the form helps streamline the review process. Each type of request requires different sections to be completed.

Additionally, some people neglect to provide a detailed medical history. This section is vital for the prescribing doctor to explain the patient's condition and previous treatments. Providing insufficient information may lead to denial.

Many applicants also forget to specify the drug’s administration site. This detail is important for determining the appropriate setting for treatment. Options include home, doctor’s office, or hospital.

Another mistake is not including the prescribing doctor’s information. The form requires the physician’s name, contact details, and signature. Omitting this information can halt the process entirely.

It’s also common for individuals to overlook the consent section. The plan member must authorize the exchange of personal information. Without this consent, the request cannot proceed.

Lastly, some people fail to follow up after submitting the form. It’s important to check in with Express Scripts Canada to confirm that the request is being processed. Following up can help address any potential issues early on.

By avoiding these mistakes, plan members can improve their chances of a smooth and timely approval process for their medication.

Documents used along the form

The Express Scripts Prior Authorization form is a crucial document for plan members seeking approval for medications that require prior authorization. Along with this form, several other documents may be necessary to ensure a smooth process. Below is a list of commonly used forms and documents that can accompany the Prior Authorization request.

Patient Assistance Program Application: This document is used to apply for financial assistance programs that help cover the costs of medications for eligible patients.
Provincial Coverage Decision Letter: If a patient has sought reimbursement under a provincial plan, this letter indicates whether the drug was approved or denied.
Primary Insurance Reimbursement Request: This form is submitted to the primary insurance provider to request coverage for the medication prior to seeking prior authorization.
Clinical Information Summary: A summary provided by the prescribing doctor that outlines the patient’s medical history and the clinical rationale for the requested medication.
Previous Therapy Documentation: This document details any previous treatments the patient has undergone, including outcomes and reasons for discontinuation.
Appeal Letter: If a prior authorization request is denied, this letter is used to formally appeal the decision, providing additional information or arguments for reconsideration.
Medication History Report: A report that lists all medications the patient has taken in the past, which can help establish the need for the requested drug.
Specialist Consultation Notes: Notes from specialists that provide insights into the patient’s condition and the necessity of the prescribed medication.
Authorization for Release of Information: This document grants permission for the sharing of the patient’s medical information with relevant parties involved in the prior authorization process.

Having these documents ready can help streamline the prior authorization process and improve the chances of approval. Each document plays a vital role in providing the necessary information to support the request for medication coverage.

Similar forms

Medication Request Form: Similar to the Express Scripts Prior Authorization form, this document is used to request approval for specific medications. It requires patient information, prescribing physician details, and justification for the medication, ensuring that all necessary data is collected for review.
Insurance Pre-Authorization Form: This form serves a similar purpose in obtaining approval from an insurance provider before a service or medication is rendered. It involves patient details and requires a physician's signature, mirroring the structure of the prior authorization process.
Patient Assistance Program Application: Like the Express Scripts form, this application helps patients secure financial assistance for medications. It collects personal and medical information to assess eligibility for support programs.
Prior Authorization Appeal Form: If a prior authorization request is denied, this form allows the patient or provider to contest the decision. It requires similar information as the initial request, emphasizing the importance of clinical justification.
Clinical Trial Enrollment Form: This document gathers patient information and medical history to determine eligibility for clinical trials. It parallels the prior authorization form by requiring detailed medical data and physician involvement.
Specialty Pharmacy Enrollment Form: Patients seeking medications from specialty pharmacies must complete this form. It shares similarities with the prior authorization form, as it collects information about the patient’s condition and treatment history.
Prescription Drug Coverage Request: This form is used to request coverage for specific medications not typically included in a plan. It requires detailed patient and medical information, similar to the prior authorization process.
Medicare Coverage Determination Request: For Medicare beneficiaries, this document seeks approval for medications or services. It requires comprehensive patient and medical details, akin to the Express Scripts Prior Authorization form.
Health Insurance Claim Form: Patients use this form to file claims for covered services or medications. It requires personal and medical information, reflecting the need for thorough documentation as seen in prior authorization requests.
Durable Medical Equipment (DME) Prior Authorization Form: This document is used to obtain approval for medical equipment. It requires similar patient and medical information to support the need for the equipment, aligning with the prior authorization process.

Dos and Don'ts

When filling out the Express Scripts Prior Authorization form, there are important guidelines to follow. Here are ten things you should and shouldn't do:

Do complete all required sections accurately.
Don't leave any mandatory fields blank; doing so may lead to automatic denial.
Do provide clear and detailed information about the patient's medical condition.
Don't include genetic test information, as it is not permitted.
Do attach any necessary decision letters from provincial plans or primary coverage.
Don't forget to have the prescribing doctor complete their section of the form.
Do ensure that the contact information is up-to-date and accurate.
Don't submit the form without reviewing it for errors or omissions.
Do keep a copy of the completed form for your records.
Don't assume approval; completion of the form does not guarantee reimbursement.

Following these guidelines can help streamline the process and improve the chances of approval for the requested medication.

Misconceptions

Here are nine common misconceptions about the Express Scripts Prior Authorization form:

Misconception 1: The form guarantees approval for the medication.

Completion and submission of the form does not guarantee that the request will be approved. Approval is based on a review process that adheres to specific clinical criteria.

Misconception 2: Only the prescribing doctor can submit the form.

The plan member must complete Part A of the form before taking it to their doctor for completion of Part B. Both parts are necessary for submission.

Misconception 3: There are no fees associated with the form.

Any fees related to the completion of the form are the responsibility of the plan member. It is important to be aware of potential costs.

Misconception 4: The plan member will be notified immediately of the decision.

The plan member will receive notification regarding the approval or denial of their request, but this may take time after submission.

Misconception 5: The prescribing doctor does not need to provide detailed information.

It is essential for the prescribing doctor to complete all required sections and provide relevant medical history for the approval process.

Misconception 6: All drugs require prior authorization.

Not all medications require prior authorization. Only specific drugs listed in the Prior Authorization Program are subject to this process.

Misconception 7: There is no right to appeal a denied request.

Plan members have the right to appeal any decision made by Express Scripts Canada regarding prior authorization requests.

Misconception 8: The form can be submitted without any supporting documents.

Supporting documents, such as provincial decision letters, may be required. Failing to include these can result in denial.

Misconception 9: The form can be submitted via any method.

The completed form must be faxed or mailed to Express Scripts Canada. Other submission methods are not accepted.

Key takeaways

When navigating the Express Scripts Prior Authorization form, there are several important points to keep in mind. Here are key takeaways to ensure a smooth process:

Complete the Form Accurately: The plan member must fill out Part A of the form completely before giving it to the prescribing doctor for Part B.
Responsibility for Fees: Any fees associated with completing the form fall on the plan member.
Three Steps to Submission: Follow the three steps: complete Part A, have the prescribing doctor fill out Part B, and then fax or mail the form to Express Scripts Canada.
Approval is Not Guaranteed: Simply submitting the form does not ensure that the request will be approved. Approval is based on clinical criteria and supporting evidence.
Right to Appeal: If a request is denied, the plan member has the right to appeal the decision made by Express Scripts Canada.
Notification of Decision: The plan member will receive notification regarding the approval or denial of the request, which will also be sent to the prescribing doctor if requested.
Provide Complete Medical Information: The prescribing doctor must include all relevant medical information and history in Part B to avoid automatic denial due to incomplete fields.

By following these guidelines, plan members can enhance their chances of successfully obtaining prior authorization for their medications.