The Express Scripts Prior Authorization form is a crucial document for patients prescribed medications that require pre-approval before the insurance company agrees to cover them. This process involves the patient and prescribing doctor completing specific sections of the form and submitting it to Express Scripts for review. It's designed to ensure that medications are used appropriately and are covered under the patient’s insurance plan. To simplify access to your medication, click the button below to fill out your form.
Navigating the landscape of medication coverage under health insurance plans can often be complex and requires understanding specific processes such as the Express Scripts Prior Authorization form. This crucial document is a foundational piece for plan members who are prescribed medications falling under the category that requires prior authorization, a step that ensures certain prescriptions are covered under their health plan. The process is delineated into three straightforward steps, beginning with the plan member completing initial details, followed by the prescribing physician filling out pertinent medical information, and culminating with the submission of this comprehensive form to Express Scripts Canada. However, the journey does not end with submission; the approval process is stringent, relying on pre-defined clinical criteria and evidence-based protocols to make a determination. Approval can unlock reimbursement for the specific medication, but it's important to note that completion and submission of this form do not guarantee this outcome. Furthermore, should there be a need, the decision made by Express Scripts Canada is not final and can be appealed. The form, meticulously designed to collate extensive patient information and thorough details regarding the prescribed medication and its intended use, plays a pivotal role in the ongoing management and administration of group benefit plans, reinforcing the interdependence between plan members, healthcare providers, and administrators.
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 requires careful attention to ensure that your medication needs are properly addressed and considered for coverage. This form is a necessary step for plan members who have been prescribed a medication that demands prior authorization. By accurately completing this form, you provide essential information needed for Express Scripts Canada® to review your medication request. The process involves collaboration between you and your prescribing doctor, highlighting the need for clear communication and detailed information about your medical condition and prescription needs. Hereafter is a step-by-step guide to assist you in completing this process efficiently.
Upon submission, the review process begins, and it's important to understand that completion of this form does not guarantee approval. You will be notified of the decision, which is based on pre-defined clinical criteria. If the request is approved, reimbursement for the prior authorized drug will be processed through your private drug benefit plan. Express Scripts Canada also provides an option to appeal the decision, ensuring that you have the opportunity to contest a denial. This process underscores the importance of thorough documentation and collaboration between you, your doctor, and Express Scripts Canada to facilitate a seamless review.
What is a Prior Authorization form from Express Scripts?
A Prior Authorization form from Express Scripts is a document that must be completed and submitted when a plan member is prescribed medication that requires prior authorization. This form ensures that prescribed medications meet certain criteria before they are approved for coverage under the plan. The form involves three main steps: completion by the plan member, the prescribing doctor, and then submission to Express Scripts for review.
Who is responsible for the fees associated with completing the Prior Authorization form?
The fees related to the completion of the Express Scripts Prior Authorization form are the responsibility of the plan member. This includes any costs incurred during the process of obtaining the required information or documentation from healthcare providers.
How does the submission process work for the Prior Authorization form?
To submit the Prior Authorization form, the plan member must first complete Part A of the form. Then, the prescribing doctor completes Part B. Once both sections are filled out, the form can be faxed or mailed to Express Scripts Canada at the provided contact information. The form must be fully completed to avoid automatic denial.
Is approval guaranteed after submitting the form?
No, completion and submission of the Express Scripts Prior Authorization form do not guarantee approval. The approval decision is based on pre-defined clinical criteria related to the medication's Health Canada approved indications and evidence-based clinical protocols. Only after thorough review and approval will reimbursement for the prior authorized drug be made through the private drug benefit plan.
How will I know if my request has been approved or denied?
Plan members will be notified of the decision regarding their prior authorization request. This decision, whether approval or denial, will also be communicated to the prescribing doctor by fax if such communication is requested. It ensures both the plan member and the prescribing doctor are informed of the outcome.
What happens if my request is denied?
If a request for prior authorization is denied, plan members have the right to appeal the decision made by Express Scripts Canada. This provides an additional opportunity to present further information or clarification that might affect the decision.
Do I need to provide information on other coverage or support programs?
Yes, the Prior Authorization form requests information regarding any patient support programs in which the patient is enrolled, any provincial coverage applications, and if there is primary coverage from another plan. This information helps in assessing the need and eligibility for coverage under the specific request.
What if this is not the first time I am applying for Prior Authorization for the same drug?
If you are applying for a renewal of Prior Authorization for the same drug, certain sections of the form specified for renewal information must be filled out. This includes providing details on the clinical response to the requested drug and any previous authorization letters if applicable. It's essential to indicate it's a renewal to expedite the review process based on past use and response to the medication.
Filling out the Express Scripts Prior Authorization form can be complex, and errors can delay the approval process. One common mistake is incomplete information. Every field is important, and leaving blanks can result in automatic denial. To avoid this, fill in 'N/A' for non-applicable sections instead of leaving them blank.
Another error is not attaching supporting documentation. For example, if a patient has applied for reimbursement under a provincial plan, or if there is a decision letter from a primary plan, these documents must be attached. Failing to do so can hinder the review process, as these documents provide crucial context for the request.
Plan members often overlook the need for both the plan member and the prescribing doctor to complete their respective sections. The form is divided into Part A (for the plan member) and Part B (for the doctor). Both parts must be filled out accurately. Skipping sections or assuming one party has completed their part can lead to issues in processing the request.
Incorrect patient information is a subtle yet significant mistake. This includes misspelling names, wrong insurance carrier numbers, or inaccurate contact details. Such errors can not only delay the process but also risk misidentification of the patient or their coverage details.
Another common mistake is not carefully reviewing the drug requested section. Ensuring the drug name, dose, administration method, frequency, and duration are accurately entered is crucial. Mistakes here can lead to confusion about the treatment plan, affecting approval.
When detailing the medical condition and treatment history in Part B, specificity is key. Vague descriptions or incomplete treatment histories can impede the comprehensiveness of the review. Providing detailed information, including reasons for cessation of previous therapies, can support a stronger case for approval.
Failing to specify whether the drug will be used according to its Health Canada approved indications is a critical oversight. This decision significantly influences the approval process, as reimbursement is often tied to these guidelines.
Not indicating the site of drug administration (home, doctor's office, etc.) might seem minor but is essential for a full understanding of the treatment plan. This information can affect logistics, administration, and overall approval considerations.
Lack of clarity on whether this is a first-time application or a renewal can lead to unnecessary delays. The form differentiates between initial requests and renewals, each with distinct information requirements. Clearly marking the appropriate option ensures the request is processed correctly.
Finally, neglecting to sign the authorization section by the plan member can invalidate the entire request. This signature is a necessary formality that grants permission for the exchange of information between parties and must be included for the process to move forward.
Avoiding these common pitfalls can streamline the prior authorization process, facilitating quicker access to necessary medications. Ensuring accuracy, completeness, and clarity in every section of the form is essential for a smooth review and approval process.
When navigating the complex process of obtaining medications that require prior authorization, such as with the Express Scripts Prior Authorization form, it's common to need additional documents and forms. These help in providing a comprehensive view of the patient's medical history, medication needs, and insurance details. Understanding these documents not only streamlines the process but also enhances the efficacy of communication between patients, healthcare providers, and insurance companies.
Together, these forms and documents paint a full picture of the patient's health needs and circumstances, facilitating the prior authorization process. They ensure that healthcare providers can make well-informed decisions, insurance companies can assess coverage eligibility accurately, and patients can receive the medications they need in a timely manner.
The Express Scripts Prior Authorization form shares similarities with the Medicare Part D Coverage Determination Request Form. Both documents are used to request coverage for prescription drugs not initially approved by the plan. The Medicare form, like the Express Scripts document, requires details about the patient, the prescribing physician, and the medication requested. Physicians must provide medical justification for the requested medication, underscoring their role in the approval process. This form also emphasizes the insurance provider's decision is based on specific criteria and documentation provided.
Another related document is the Medical Exception Request Form, which is used when a patient needs a medication that is not on their health plan's formulary. This form, akin to the Express Scripts Prior Authorization form, involves filling out patient information, medication requested, and providing a detailed rationale from the prescribing healthcare provider. The form acts as a bridge to negotiate between standard formulary guidelines and patient-specific needs, requiring thorough clinical justification for the non-formulary medication request.
The Prescription Drug Prior Authorization Request Form used by insurance companies is also notably similar. It streamlines the process for obtaining approval for prescription medications that require prior authorization. Just like the Express Scripts form, it includes sections for patient details, medication requested, and physician information, underscoring the collaborative effort between the patient, provider, and insurance to validate the necessity of the prescription. This document aligns with the detailed review process, seeking the optimal clinical outcome for the patient within the parameters of the insurance policy.
A Drug Exception Request Form is tailored for cases where a patient or doctor seeks access to a drug not covered under a patient’s health plan. This document parallels the Express Scripts Prior Authorization form in its function to bridge gaps in coverage for specific medical needs not anticipated in standard formulary lists. Both forms necessitate comprehensive details regarding the patient's condition and the rationale for the specific medication request, establishing a structured approach to addressing exceptional cases in patient care.
The Specialty Medication Prior Authorization Form specifically targets high-cost specialty medications requiring detailed scrutiny before approval. Similar to the Express Scripts form, it usually mandates information about the patient, a detailed medical rationale for the request, and expected outcomes. This type of form highlights the complex interplay between clinical need, medication cost, and insurance considerations, mirroring the Express Scripts procedure in ensuring only justified prescriptions are covered.
The Prior Authorization Appeal Form provides a pathway for contesting a denied medication request, resembling the section in the Express Scripts form that mentions the right to appeal. Both forms serve critical roles in the healthcare process by advocating for patient rights and ensuring their access to necessary medications. The appeal process involves a detailed submission of medical evidence and rationale, emphasizing patient-specific considerations over broad policy guidelines.
Lastly, the Patient Assistance Program Enrollment Form represents an auxiliary route similar to the assistance inquiry within the Express Scripts form. While not a direct request form for medication approval, it aligns with the objective of securing medication for patients through alternative means, such as manufacturer assistance programs. This form, like the Express Scripts document, often gathers comprehensive patient information and medical necessity documentation to qualify the patient for assistance, reflecting the broader ecosystem of support for accessing prescribed medications.
Filling out the Express Scripts Prior Authorization form requires attention to detail and an understanding of the process. To ensure a smooth and accurate submission, here’s a list of dos and don'ts:
What You Should Do:
What You Shouldn’t Do:
By following these guidelines, plan members can improve the accuracy of their submissions and facilitate a smoother review process by Express Scripts Canada.
When navigating the complexities of health insurance and prescription coverage, the Express Scripts Prior Authorization form plays a crucial role. Yet, there are several misconceptions about this process that may lead to confusion. Understanding these misconceptions can help ensure a smoother experience for both patients and healthcare providers.
Many believe that the prior authorization process is just a bureaucratic hurdle. However, this step is designed to ensure that prescribed medications are covered under the patient's health plan and are medically necessary according to Health Canada's approved indications and evidence-based protocols. It's a safeguard to promote effective and safe medication use.
Some might expect that completing and submitting the prior authorization form results in an immediate decision. In reality, the review process involves a detailed assessment of the prescription against clinical criteria and could take several days. Patients and doctors are encouraged to start the process as early as possible to avoid delays in medication access.
There's a common assumption that once a prior authorization form is submitted, approval is just a formality. However, approval is not guaranteed; it’s dependent on a review against specific clinical criteria and the patient's drug benefit plan. In cases where a request is denied, patients and prescribers have the right to appeal the decision.
Completing and submitting the form is not the final step. Communication continues beyond this point—patients and prescribers are notified of the approval or denial. Additionally, for approved medications, doctors may need to provide further information or clarify treatment plans, ensuring that the medication is used effectively and safely.
Understanding these common misconceptions about the Express Scripts Prior Authorization form can lead to better preparedness and fewer surprises during the medication approval process. It's all about ensuring that patients receive the right medications in a timely and efficient manner.
Filing an Express Scripts Prior Authorization form involves a clear, step-by-step process designed to assess whether specific medications will be covered under a patient's health plan. Here are several critical takeaways to remember when completing and utilizing this form:
Understanding and accurately completing the Express Scripts Prior Authorization form is vital for individuals seeking coverage for certain medications. It is not just about filling out a form but navigating through a structured process that evaluates the necessity and appropriateness of medication under specific health plans. Hence, patients and healthcare providers must work closely together to meet all requisites and provide comprehensive information to facilitate the review process.
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