The Express Scripts Prior Authorization form is a crucial document that plan members must complete when prescribed a medication requiring prior approval. This form ensures that the request for coverage is properly evaluated, allowing for reimbursement through the private drug benefit plan if approved. To get started, fill out the form by clicking the button below.
When it comes to accessing certain medications, the Express Scripts Prior Authorization form plays a crucial role in the process. This form is essential for plan members who have been prescribed drugs that require prior approval before reimbursement can occur. The responsibility for completing and submitting this form lies with the plan member, and any associated fees are also theirs to bear. The process is straightforward, consisting of three key steps: first, the plan member fills out Part A, providing necessary personal and insurance information; next, the prescribing doctor completes Part B, detailing the medical condition and drug history; finally, the completed form must be faxed or mailed to Express Scripts Canada. It's important to note that submitting this form does not guarantee approval. Approval hinges on a review of clinical criteria, primarily based on Health Canada’s approved indications and evidence-based protocols. After the review, plan members will receive notification regarding the outcome, and they also have the right to appeal if their request is denied. Understanding this process can empower plan members to navigate the complexities of medication access with greater confidence.
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
Completing the Express Scripts Prior Authorization form is a crucial step in ensuring that your medication request is reviewed and processed promptly. Follow the steps outlined below to fill out the form accurately and efficiently.
After submission, you will be notified of the decision regarding your prior authorization request. It is important to note that this process does not guarantee approval, but it is a necessary step to potentially receive reimbursement for your medication.
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 is covered under the member's private drug benefit plan. It serves as a formal request for approval from Express Scripts Canada, which assesses the request based on predefined clinical criteria and Health Canada approved indications.
What steps are involved in completing the Prior Authorization form?
Completing the Prior Authorization form involves three straightforward steps. First, the plan member fills out Part A of the form, providing essential personal and insurance information. Next, the prescribing doctor must complete Part B, detailing the medical condition and justifying the need for the prescribed medication. Finally, the completed form must be faxed or mailed to Express Scripts Canada for review. 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?
After submission, the request undergoes a review process. It is important to note that completing and submitting the form does not guarantee approval. The plan member will be notified of the decision, whether it is an approval or denial. This notification will also be communicated to the prescribing doctor if requested. If the request is denied, the plan member has the right to appeal the decision made by Express Scripts Canada.
Are there any costs associated with the Prior Authorization form?
Yes, any fees related to the completion and submission of the Prior Authorization form are the responsibility of the plan member. It is advisable for members to be aware of these potential costs when initiating the prior authorization process.
When filling out the Express Scripts Prior Authorization form, many individuals inadvertently make mistakes that can delay the approval process for their medication. One common error is failing to complete all required fields in Part A. This section asks for essential patient information, such as the patient's date of birth and insurance details. If any of these fields are left blank, it can lead to an automatic denial of the request. Ensuring that every box is filled out completely is crucial for a smooth submission.
Another frequent mistake occurs in Part B, where the prescribing doctor must provide detailed information about the patient's medical condition and drug history. Some doctors may overlook the importance of including all mandatory information. For instance, if the section regarding previously tried therapies is incomplete, it could result in a denial. It is vital for both the patient and the doctor to understand that every piece of information requested is necessary for the approval process.
Many plan members also forget to attach supporting documentation, such as the provincial decision letter or previous approval letters. This oversight can be detrimental. Without this documentation, Express Scripts Canada may not have enough evidence to support the request, leading to a denial. Always double-check that all necessary attachments are included before submitting the form.
In addition, some individuals may not clearly indicate whether the drug will be used according to its Health Canada approved indications. This is a key factor in the approval process. If the form states "No" to this question without sufficient justification, it could lead to an immediate denial. Providing clear and accurate information about the intended use of the medication is essential.
Lastly, timing can also be an issue. Many people submit the form without allowing enough time for the review process, which can take several days. Submitting the form too close to when the medication is needed can create unnecessary stress and complications. Planning ahead and submitting the request as early as possible can help ensure timely access to necessary medications.
The Express Scripts Prior Authorization form is a crucial document for individuals seeking approval for medications that require prior authorization. In addition to this form, several other documents may be necessary to support the authorization process. Below is a list of commonly used forms and documents that often accompany the Express Scripts Prior Authorization form.
These documents work together to provide a comprehensive overview of the patient’s medical needs and insurance coverage, facilitating a smoother prior authorization process. Ensuring that all relevant forms are completed and submitted can significantly improve the chances of approval for the requested medication.
Medicare Prior Authorization Request Form: This document is used by Medicare beneficiaries to request approval for specific medications. Similar to the Express Scripts form, it requires patient and physician information and is subject to review based on medical necessity.
Medicaid Prior Authorization Form: Medicaid recipients must complete this form to obtain prior authorization for certain drugs. Like the Express Scripts form, it involves both patient and provider sections and hinges on clinical criteria for approval.
Commercial Insurance Prior Authorization Form: Many private insurers require this form to authorize medication coverage. It shares the same structure, requiring patient details and physician input, with a focus on medical justification.
Pharmacy Benefit Manager (PBM) Prior Authorization Form: This form is utilized by PBMs to assess requests for medication coverage. It mirrors the Express Scripts form in its need for thorough patient and prescriber information and review processes.
Specialty Pharmacy Prior Authorization Form: Specialty pharmacies often require this document for high-cost medications. Similarities include the need for detailed medical history and treatment plans to support the authorization request.
Health Insurance Marketplace Prior Authorization Form: Individuals enrolled through the Health Insurance Marketplace may need to submit this form for certain medications. It follows the same patient-doctor collaboration as the Express Scripts form.
Workers' Compensation Drug Authorization Form: Injured workers may use this form to request medication approval. It requires detailed medical documentation, akin to the Express Scripts process, to justify the need for specific drugs.
Employer-Sponsored Health Plan Prior Authorization Form: Employees seeking medication coverage through employer plans must fill out this form. It includes sections for both patient and physician, similar to the Express Scripts form.
Clinical Trial Medication Authorization Form: Patients participating in clinical trials may need this form to access trial medications. It requires comprehensive medical information and justification, paralleling the Express Scripts authorization requirements.
Patient Assistance Program Application: This form is used to apply for free or reduced-cost medications from pharmaceutical companies. It requires patient and provider information, reflecting the same collaborative approach found in the Express Scripts form.
When filling out the Express Scripts Prior Authorization form, it is important to follow certain guidelines to ensure a smooth process. Here are nine things you should and shouldn't do:
Understanding the Express Scripts Prior Authorization form can be challenging, and several misconceptions may hinder the process. Here are eight common misconceptions along with clarifications to help plan members navigate this important document.
Many believe that submitting the form ensures their request will be approved. In reality, completion does not guarantee approval. Each request is reviewed based on specific clinical criteria set by Express Scripts Canada.
This form requires input from both the plan member and the prescribing doctor. The plan member completes Part A, while the doctor is responsible for Part B, which includes critical medical information.
It is important to note that any fees related to completing the form fall on the plan member. Understanding this responsibility can help avoid unexpected costs.
Plan members will be notified of both approval and denial decisions. This ensures that they are fully informed about the status of their request.
The review process may take time, as each request is evaluated carefully against established clinical criteria. Patience is essential during this period.
Plan members have the right to appeal a denial. Understanding the appeals process can empower members to advocate for their needs.
Not every medication necessitates prior authorization. Only specific drugs as outlined by the plan require this additional step, which can vary by individual plans.
Supporting documents, such as decision letters from provincial plans or previous therapy details, may be required. Omitting these can lead to delays or denials.
Filling out the Express Scripts Prior Authorization form is a critical step for plan members seeking medication that requires prior approval. Here are some key takeaways to ensure a smooth process: