This form is based on Express Scripts standard criteria and may not be applicable to all patients; certain plans and situations may require additional information beyond what is specifically requested.

Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any questions about the process or required information, please …

Express Scripts facsimile machines are secure and in compliance with HIPAA privacy standards. The provision of the information requested in this form is for your patient's benefit. Express Scripts does …

AUTHORIZATION REQUEST FORM Patient Name: ID#: Instructions: Please fill out all applicabl. sections on both pages completely and legibly. Attach any additional documentation that is important …

View, download and print Express Scripts Prior Authorization - General Request pdf template or form online. 44 Express Scripts Prior Authorization Form Templates are collected for any of your needs.

Express Scripts partners with CoverMyMeds to offer electronic prior authorization (ePA) services. To start an Express Scripts prior auth, select the appropriate Express Scripts PA form.

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Use this form to ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan with refills of up to one year, if appropriate.