EduSpace
Homepage ⇨ Blank Express Scripts Prior Authorization PDF Form
Article Guide

The Express Scripts Prior Authorization form is an essential tool for plan members who require specific medications that necessitate prior approval. This form streamlines the process, ensuring that both the patient and the prescribing doctor can provide the necessary information for a timely review. The form consists of two main parts: Part A, which is completed by the plan member, and Part B, filled out by the prescribing physician. In Part A, the patient provides personal details, insurance information, and answers questions regarding their medical history and any patient assistance programs they may be enrolled in. Following this, the prescribing doctor completes Part B, detailing the medical condition and the specific drug requested, along with any relevant treatment history. Once both sections are filled out, the completed form must be submitted to Express Scripts Canada via fax or mail. It is crucial to understand that submitting this form does not guarantee approval; the request will be evaluated based on established clinical criteria. Plan members will receive notification of the decision, which will also be communicated to the prescribing doctor if requested. If the request is denied, members have the right to appeal the decision, ensuring that they remain informed and engaged throughout the process.

Document Preview

Request 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:

Mail:

Express Scripts Canada Clinical Services

Express Scripts Canada Clinical Services

1 (855) 712-6329

5770 Hurontario Street, 10th 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.

Please continue to page 2.

Page 1

Request for Prior Authorization

Part A – Patient

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

Patient information

 

 

 

 

 

 

First Name:

 

 

 

Last Name:

 

 

Insurance Carrier Name/Number:

 

 

 

 

 

Group number:

 

 

 

Client ID:

 

 

Date of Birth (DD/MM/YYYY):

/

/

Relationship:

□ Employee

□ Spouse □ Dependent

Language:

□ English

□

French

Gender:

□ Male

□ Female

Address:

 

 

City:

Province:

Postal Code:

Email address:

 

 

Telephone (home):

Telephone (cell):

Telephone (work):

Patient Assistance Program

 

 

Is the patient enrolled in any patient support program? ❒ Yes

❒ No

Contact name:

Telephone:

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.

Plan Member Signature

Date

Page 2

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 AuthorizationRenewal for this drug *Fill sections 1, 3 and 4*

SECTION 1 – DRUG REQUESTED

Drug name:

Dose Administration (ex: oral, IV, etc) FrequencyDuration

Medical condition:

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

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)

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

Page 3

Request for Prior Authorization

Section 2 - Continued

Please list previously tried therapies

 

Duration of therapy

Reason for cessation

Drug

Dosage and

 

Inadequate/

Allergy/

 

administration

 

 

From

To

Suboptimal

Drug

 

response

Intolerance

 

 

 

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

 

 

 

❒

❒

SECTION 3 – RENEWAL INFORMATION

Date of treatment initiation:

Details on clinical response to requested drug

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

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

SECTION 4 – PRESCRIBER INFORMATION

Physician’s Name:

 

Address:

 

Tel:

Fax:

License No.:

Specialty:

Physician Signature:

Date:

Page 4

➤ PDF File

Form Specifications

Fact Name Details
Purpose The Express Scripts Prior Authorization form is used by plan members to request approval for medications that require prior authorization before they can be reimbursed.
Responsibility for Fees Any fees associated with completing this form are the responsibility of the plan member, not the healthcare provider or the insurance company.
Submission Process Plan members must complete Part A, and the prescribing doctor must complete Part B. The completed form can be submitted via fax or mail to Express Scripts Canada.
Review Process Submitting the form does not guarantee approval. Requests are evaluated based on clinical criteria and Health Canada approved indications.
Notification of Decision Plan members will be informed of the approval or denial of their request. This information is also shared with the prescribing doctor if requested.
Right to Appeal Plan members have the right to appeal any decision made by Express Scripts Canada regarding their prior authorization request.

Express Scripts Prior Authorization: Usage Guidelines

Completing the Express Scripts Prior Authorization form is an important step for plan members seeking coverage for certain medications. This process involves gathering specific information from both the patient and the prescribing doctor. Once the form is filled out and submitted, it will undergo a review to determine if the request meets the necessary criteria for approval.

  1. Complete Part A: As the plan member, fill in your personal information in Part A of the form. This includes your name, insurance details, date of birth, and contact information. Be sure to indicate your relationship to the insurance policy and whether you are enrolled in any patient assistance programs.
  2. Consult Your Doctor: Take the completed Part A to your prescribing doctor. They will need to fill out Part B, which requires detailed medical information about your condition and the requested medication.
  3. Submit the Form: Once both parts of the form are completed, submit it to Express Scripts Canada. You can either fax it to 1 (855) 712-6329 or mail it to their office at 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5.

After submission, you will receive a notification regarding the approval or denial of your request. Remember, the approval process is based on specific clinical criteria, and you have the right to appeal if your request is denied.

Your Questions, Answered

What is the purpose of the Express Scripts Prior Authorization form?

The Express Scripts Prior Authorization form is designed for plan members who have been prescribed a medication that requires prior authorization. This form must be completed and submitted to ensure that the medication can be reimbursed through the member's private drug benefit plan. The completion of this form is essential for the approval process, which is based on clinical criteria established by Health Canada and supporting evidence-based protocols.

Who is responsible for completing the Prior Authorization form?

The process involves two parties: the plan member and the prescribing doctor. The plan member is responsible for completing Part A of the form, which includes personal and insurance information. After this, the plan member must take the form to their prescribing doctor, who will complete Part B, providing necessary medical information related to the medication request.

What are the steps involved in submitting the Prior Authorization form?

There are three main steps for submitting the form. First, the plan member completes Part A of the form. Second, the prescribing doctor fills out Part B. Finally, the completed form must be faxed or mailed to Express Scripts Canada. The fax number is 1 (855) 712-6329, and the mailing address is 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5.

What happens after the form is submitted?

Once the form is submitted, it does not guarantee approval of the medication request. Express Scripts Canada will review the request based on predetermined clinical criteria. The plan member will receive notification regarding the approval or denial of the request. If requested, the prescribing doctor will also be informed of the decision by fax.

Can a plan member appeal a denial decision?

Yes, if a request for prior authorization is denied, the plan member has the right to appeal the decision made by Express Scripts Canada. The appeal process allows the plan member to present additional information or clarify any aspects of the initial request that may have contributed to the denial.

What information is required from the prescribing doctor?

The prescribing doctor must provide detailed information about the patient's medical condition and drug history in Part B of the form. This includes the name of the requested drug, dosage, frequency, and the medical condition for which the drug is being prescribed. The doctor must also indicate whether the drug will be used according to its Health Canada approved indications and provide relevant clinical details to support the request.

Are there any fees associated with completing the Prior Authorization 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 for members to be aware of these potential costs when initiating the prior authorization process.

Common mistakes

  1. Failing to complete all required fields in Part A and Part B. Leaving any mandatory sections blank can lead to an automatic denial of the request.

  2. Not providing accurate patient information. Ensure that the patient's name, date of birth, and insurance details are correct to avoid processing delays.

  3. Neglecting to attach supporting documents. If applicable, include the provincial decision letter and any other relevant documentation to strengthen the request.

  4. Using incomplete medical history. Be thorough when detailing the patient’s medical condition and previous treatments to meet the approval criteria.

  5. Forgetting to indicate the site of drug administration. Specify whether the drug will be administered at home, in a doctor's office, or a hospital setting.

  6. Ignoring the authorization section. The plan member must sign and date the authorization to allow information exchange between the provider and Express Scripts Canada.

  7. Submitting the form without consulting the prescribing doctor. Ensure the prescribing physician completes their section accurately before submission.

  8. Not following the submission guidelines. Remember to fax or mail the completed form to the correct address provided by Express Scripts Canada.

Documents used along the form

The process of obtaining prior authorization for medication through Express Scripts involves several important documents. Each document serves a unique purpose and is essential for ensuring that the request is processed efficiently. Below is a list of forms that are often used in conjunction with the Express Scripts Prior Authorization form.

  • Patient Assistance Program Enrollment Form: This document is used to enroll patients in programs that provide financial assistance for medications. It includes information about the patient's financial situation and their eligibility for support.
  • Provincial Drug Reimbursement Application: This form is submitted to provincial health plans to seek reimbursement for medications. It typically requires details about the drug, the patient's medical condition, and any prior decisions made by the provincial plan.
  • Prior Authorization Renewal Form: For patients who have previously received prior authorization, this form is used to request a renewal. It includes sections for detailing the patient's ongoing medical condition and response to treatment.
  • Clinical Documentation: This document includes medical records and other relevant information that supports the need for the prescribed medication. It may consist of lab results, treatment history, and notes from healthcare providers.
  • Appeal Letter: If a prior authorization request is denied, patients may submit an appeal letter. This letter outlines the reasons for the appeal and may include additional supporting documentation to strengthen the case for approval.

Understanding these documents and their purposes can help streamline the prior authorization process. Each form plays a crucial role in ensuring that patients receive the medications they need in a timely manner. Proper completion and submission of these documents can significantly impact the outcome of the authorization request.

Similar forms

  • Prior Authorization Request Form: Similar to the Express Scripts form, this document requires both the patient and prescribing physician to provide detailed information about the medication and medical necessity before approval can be granted.
  • Medication Prior Authorization Form: This form serves the same purpose, ensuring that the prescribed medication meets specific criteria set by the insurance provider before reimbursement is approved.
  • Insurance Pre-Approval Form: Like the Express Scripts form, this document necessitates patient and provider input, focusing on the clinical justification for the treatment requested.
  • Drug Utilization Review Form: This document reviews prescribed medications for appropriateness, aligning with the Express Scripts form's goal of ensuring that drugs are used correctly and effectively.
  • Clinical Evaluation Form: This form collects necessary clinical data from healthcare providers, paralleling the detailed medical history and drug use information required by the Express Scripts form.
  • Patient Assistance Program Application: Similar in structure, this application seeks information about the patient's eligibility for assistance, requiring both patient and physician signatures to process the request.
  • Formulary Exception Request: This document allows healthcare providers to request coverage for medications not on the formulary, much like the Express Scripts form aims to secure approval for specific drugs based on clinical need.

Dos and Don'ts

When filling out the Express Scripts Prior Authorization form, it’s crucial to follow certain guidelines to ensure your request is processed smoothly. Here are some important dos and don’ts:

  • Do complete all required sections of the form accurately.
  • Do ensure that the prescribing doctor fills out Part B completely.
  • Do provide any necessary supporting documents, such as decision letters from provincial plans.
  • Do double-check all patient information for accuracy before submission.
  • Don’t leave any mandatory fields blank; this can lead to automatic denial.
  • Don’t submit the form without the required signatures from both the plan member and the prescribing doctor.
  • Don’t forget to specify if the application is a first-time request or a renewal.
  • Don’t provide unnecessary personal information that is not relevant to the request.

By adhering to these guidelines, you increase the likelihood of a successful prior authorization request. Time is of the essence, so ensure you complete the form promptly and accurately.

Misconceptions

Misconceptions about the Express Scripts Prior Authorization form can lead to confusion and delays in receiving necessary medications. Here are eight common misconceptions:

  • Misconception 1: The form guarantees approval.

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

  • Misconception 2: Only doctors can submit the form.

    • While the prescribing doctor must complete part of the form, the plan member is responsible for submitting it. Both parties must collaborate to ensure all sections are filled out correctly.

  • Misconception 3: Fees are covered by Express Scripts.

    • Any fees related to the completion of the form are the responsibility of the plan member. It is important to be aware of this financial obligation before proceeding.

  • Misconception 4: The form is the same for all medications.

    • Different medications may require different information on the form. It is crucial to provide accurate details specific to the requested drug and the patient's condition.

  • Misconception 5: The process is quick and straightforward.

    • The review process can take time. Plan members should not expect immediate responses, as approvals depend on thorough evaluations of submitted information.

  • Misconception 6: All information is optional.

    • All fields marked as mandatory must be filled out. Leaving any required fields blank will result in an automatic denial of the request.

  • Misconception 7: You cannot appeal a denial.

    • Plan members have the right to appeal any decision made by Express Scripts Canada. Understanding the appeals process is essential for those who receive a denial.

  • Misconception 8: Only new requests need prior authorization.

    • Renewals for medications also require prior authorization. It is important to complete the appropriate sections of the form, depending on whether it is a first-time request or a renewal.

Key takeaways

Here are some key takeaways about filling out and using the Express Scripts Prior Authorization form:

  • Complete the Form: The plan member must fill out Part A of the form before taking it to their prescribing doctor for Part B completion.
  • Submission Methods: Once both parts are filled out, the completed form can be faxed or mailed to Express Scripts Canada.
  • Approval Not Guaranteed: Submitting the form does not guarantee approval. Approval is based on specific clinical criteria set by Express Scripts Canada.
  • Notification of Decision: The plan member will be informed whether their request has been approved or denied. The prescribing doctor will also receive this information if requested.
  • Right to Appeal: If the request is denied, the plan member has the right to appeal the decision made by Express Scripts Canada.
  • Fees Responsibility: Any fees related to completing the Prior Authorization form are the responsibility of the plan member.