The Express Scripts Prior Authorization form is a necessary document for plan members prescribed medication that demands prior approval before coverage. This form serves as a bridge between patients, healthcare providers, and insurance underwriters, ensuring all prescribed medications meet the insurer's requirements for necessity and efficacy based on pre-defined clinical criteria. If you or someone you know needs to navigate the complexity of medication approval, click the button below to learn how to accurately fill out and submit this essential form.
The Express Scripts Prior Authorization form serves as a pivotal tool within the realm of pharmaceutical care, streamlining the process for plan members prescribed medications that necessitate prior authorization. To use this form effectively, it first requires the completion of Part A by the plan member, followed by Part B, which must be filled in by the prescribing doctor. These steps culminate in the submission of the document to Express Scripts Canada through fax or mail, a process designed to determine the eligibility for reimbursement of the prior authorized drug through the plan member’s private drug benefit plan. However, it is crucial to acknowledge that the submission of this form does not automatically guarantee approval. The outcome, either approval or denial, is contingent upon a review process grounded in pre-defined clinical criteria, including Health Canada approved indications and evidence-based clinical protocols. In instances of denial, plan members are afforded the right to appeal the decision made by Express Scripts Canada. Furthermore, both the plan member and prescribing doctor are notified of the decision, ensuring transparency and clarity in the communication of the authorization outcome. The form additionally addresses patient and prescribing doctor responsibilities, outlining the necessity for detailed patient information, medical condition descriptions, and a thorough account of any previous therapies attempted, which collectively contribute to the comprehensive evaluation process undertaken by Express Scripts Canada.
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
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
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
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
Section 2 - Continued
Please list previously tried therapies
Duration of therapy
Reason for cessation
Drug
Dosage and
Inadequate/
Allergy/
administration
From
To
Suboptimal
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:
Tel:
License No.:
Specialty:
Physician Signature:
Date:
Page 4
Filling out the Express Scripts Prior Authorization form is an essential step for those who are prescribed medication requiring prior authorization. This process helps to determine if the prescribed medication will be covered under the plan member's benefits, based on specific criteria. The steps provided below are designed to ensure the form is completed accurately to facilitate a smooth review process. Keep in mind, completing and submitting this form does not guarantee approval, but it's the necessary first step to get there. Once the request has been reviewed, the plan member and the prescribing doctor will be informed of the decision. Should the request be denied, there exists an option to appeal the decision with Express Scripts Canada.
After submission, the form will undergo a review process. Though submission does not ensure approval, it is key to moving forward in the quest to obtain coverage for necessary medications. You will be notified of the decision, which also extends the option to appeal should the need arise. This line of communication ensures transparency and provides a clear path forward, regardless of the initial decision.
The Express Scripts Prior Authorization form is a document that needs to be completed for any medication that requires prior approval before it is covered by a plan member’s private drug benefit plan. This form must be filled out and submitted to Express Scripts Canada®, following three steps involving the plan member, the prescribing doctor, and the final submission process via fax or mail.
To submit the Express Scripts Prior Authorization form, follow these steps:
No, completing and submitting the form does not guarantee approval. The decision to approve or deny the medication request is based on pre-defined clinical criteria, the drug’s approved indications by Health Canada, and supporting evidence-based protocols. Plan members will be reimbursed for the drug only if the request is approved by Express Scripts Canada.
Plan members will be notified about the decision on their request being either approved or denied. This decision is also communicated to the prescribing doctor by fax if requested. The decision process ensures that both the plan member and the doctor are informed of the outcome.
If your request is denied, you have the right to appeal the decision made by Express Scripts Canada. It’s important to gather all relevant medical information and any additional supporting documents for a stronger appeal case.
Yes, any fees related to the completion of this form are the responsibility of the plan member. These could include, but are not limited to, charges for acquiring necessary medical records or any fees that healthcare providers might impose for completing part of the form.
When filling out the Express Scripts Prior Authorization form, people often make a range of common mistakes that can delay or negatively impact the approval process. Recognizing and avoiding these mistakes is critical for ensuring a smoother review and approval procedure.
Failing to complete all required sections, including not providing detailed information about the medical condition and drug history in Part B by the prescribing doctor.
Leaving mandatory fields blank instead of marking them with ‘N/A’ for non-applicable areas, which leads to an automatic denial as specified by the form instructions.
Omitting the plan member's signature and date at the end of Part A, which is necessary for authorizing the exchange of personal information for the purpose of benefit plan administration.
Incorrectly reporting the patient’s insurance and primary coverage details, or not attaching decision letters from provincial or primary coverage when indicated.
Not checking whether the patient is enrolled in any patient support programs and failing to provide contact details for such programs when the patient is enrolled.
Forgetting to select a language preference, causing potential communications to be in the wrong language.
Providing inaccurate patient information, such as incorrect or incomplete contact information, which can lead to the plan member not receiving notification of the decision.
Not specifying the precise drug name, dosage, administration method, frequency, and duration in the sections provided, which is critical for Express Scripts Canada to assess the request properly.
Overlooking the requirement to list previously tried therapies including the duration of therapy, reason for cessation, and outcomes, which is essential for evaluating the necessity of the requested drug.
By paying careful attention to these common pitfalls and ensuring that the form is filled out comprehensively and accurately, plan members and prescribing doctors can facilitate a more efficient review process. This not only aids in avoiding unnecessary delays but also increases the likelihood of a favorable decision regarding drug reimbursement under the member's private drug benefit plan.
When navigating healthcare and prescription benefits, forms and documents can often become the bridge between patients and the access to the medications they need. The Express Scripts Prior Authorization form is a critical piece of this process. Yet, it is frequently accompanied by several other forms and documents that ensure a thorough review and support the decision-making process. These additional materials can provide comprehensive insights into a patient's medical history, condition, and the rationale behind specific medication requests. Understanding these documents can empower patients and healthcare providers alike in navigating the complexities of medication approvals more effectively.
Understanding and gathering these documents in support of a prior authorization request can streamline the review process, making it more efficient and increasing the chances of approval. Both healthcare providers and patients play crucial roles in compiling this information, which together with the Express Scripts Prior Authorization form, creates a comprehensive packet that details the necessity and rationale for a specific medication. Ultimately, this helps bridge the gap between clinical recommendations and insurance coverage, ensuring patients receive the treatments they need in a timely manner.
Medicare Part D Prior Authorization Form: This form, used within the Medicare Part D program, necessitates similar steps to the Express Scripts Prior Authorization form. Both require medication and patient information, verification of the need for the specific prescribed medication according to clinical guidelines, and physician endorsement.
Medicaid Prior Authorization Request Form: Used for Medicaid enrollees, this document similarly demands detailed patient information, the prescribing physician's details, and medical justification for the prescribed medication. Both forms seek to ensure that medications are used appropriately and are covered by the payer.
Private Insurance Prior Authorization Form: This form is required by many private insurance companies for certain medications or treatments. Like the Express Scripts form, it collects comprehensive patient information, prescription details, and requires physician justification for the treatment, assessing eligibility for coverage.
Pharmacy Benefit Manager (PBM) Prior Authorization Form: PBMs manage prescription drug benefits on behalf of health insurers. Their prior authorization forms, similar to Express Scripts, require detailed prescription information, patient data, and a thorough medical justification for the medication request.
Specialty Medication Prior Authorization Form: Specialty medications often require these forms due to their high cost and specific usage criteria. They collect similar information to the Express Scripts form, including patient information, clinical justification for use, and prescriber details, to assess the medication's appropriateness for the patient’s condition.
Health Insurance Exchange Prior Authorization Form: Used within the health insurance marketplaces, these forms necessitate detailed patient and prescriber information alongside medical justification, akin to the Express Scripts form, aimed at ensuring that the prescribed medications are covered under the patient's health plan.
Hospital Formulary Exception Request Form: When a patient requires a medication not on the hospital's formulary, this form is used to request an exception. It resembles the Express Scripts form by requiring a detailed justification for the exception, including patient and medication information, and physician endorsement.
When dealing with the Express Scripts Prior Authorization form, certain practices should be kept in mind to ensure a smooth and effective process. Following these recommendations will help in efficiently submitting your request for medication coverage approval. Consider these dos and don'ts:
When it comes to navigating the world of medication coverage, the Express Scripts Prior Authorization form plays a crucial role. However, several misconceptions surround its use and implications. Understanding these can help in efficiently managing medication needs. Here are ten common misconceptions explained:
Any doctor can complete the form: Only the prescribing doctor is required to complete Part B of the form. This ensures that all necessary medical information and justification for the medication are provided accurately.
Prior authorization is the same as prescription approval: Completing and submitting the form does not guarantee approval. The authorization process is to ensure the drug is covered under the plan based on clinical criteria.
Once approved, medication is immediately available: Even after approval, there may be a waiting period. The plan member will be informed when the authorized medication is available for reimbursement or pickup.
The form is only for expensive medications: Prior authorization can be required for medications of any cost, depending on the health plan's guidelines and the medication’s intended use.
Submitting the form guarantees coverage: Submission only starts the review process. The decision to approve or deny coverage is based on several factors, including medication indication and clinical protocols.
The decision is final: If a request is denied, there is an appeals process available. Plan members have the right to understand the reason for denial and seek review under specific circumstances.
Prior authorization is a one-time process: For some medications, re-authorization may be required periodically to ensure the ongoing need and effectiveness of the medication.
All information submissions result in automatic approval: Mandatory information is crucial for the approval process; missing or inaccurate information can lead to automatic denial. However, not all submissions, even if complete, result in approval.
The process is solely the patient’s responsibility: While the patient initiates the request, the prescribing doctor and sometimes the pharmacist play significant roles in providing necessary medical information and justifications.
Prior authorization affects medical treatment: The process is designed to ensure that medications are used appropriately and covered under the health plan. It does not dictate the treatment plan but rather facilitates coverage for specific medications.
Understanding these nuances can help patients and healthcare providers navigate the prior authorization process more effectively, ensuring that needed medications are accessed in a timely and covered manner.
Filling out and using the Express Scripts Prior Authorization form is a significant process for plan members needing medication that requires prior authorization. Here are the key takeaways to ensure clarity and ease in this process:
Understanding these key takeaways can help streamline the prior authorization process, ensuring that all necessary information is provided, potentially leading to a positive outcome for the plan member.
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