The Express Scripts Prior Authorization form is a document that plan members must complete when prescribed a medication that requires prior approval. This form helps ensure that the prescribed drug meets specific clinical criteria established by Express Scripts Canada. To initiate the process, simply fill out the form by following the steps outlined below.
Ready to get started? Click the button below to fill out the form.
The Express Scripts Prior Authorization form is a crucial document for plan members who need to obtain approval for certain medications before they can be reimbursed by their private drug benefit plan. This form is designed to streamline the process, ensuring that both the patient and the prescribing doctor provide the necessary information. The process is divided into three straightforward steps: first, the plan member completes Part A, which gathers essential patient information; next, the prescribing doctor fills out Part B, detailing the medical condition and the requested drug; finally, the completed form is submitted to Express Scripts Canada via fax or mail. It's important to note that submitting this form does not guarantee approval; instead, requests are evaluated based on established clinical criteria and evidence-based protocols. After the review, both the patient and the prescribing doctor will be notified of the decision. If the request is denied, there is an option to appeal the decision, allowing for further consideration of the case. This form plays a vital role in ensuring that patients receive the medications they need while adhering to the guidelines set forth by health authorities.
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 a straightforward process, but it requires careful attention to detail. The form must be completed by both the plan member and the prescribing doctor. Once submitted, the request will be reviewed, and the member will be notified of the decision. Follow these steps to ensure that the form is filled out correctly.
Once the form is submitted, the review process will begin. Keep in mind that completion of the form does not guarantee approval. You will be informed of the decision, and if necessary, you have the right to appeal. Stay in touch with your prescribing doctor for updates on the approval status.
The Express Scripts Prior Authorization form is a document that plan members must complete when prescribed a medication that requires prior authorization. This form helps ensure that the medication is covered under the member's private drug benefit plan, subject to approval by Express Scripts Canada.
Any plan member who is prescribed a medication that requires prior authorization must complete this form. This includes providing personal information and details about the prescribed medication. Additionally, the prescribing doctor must also fill out part of the form to support the request.
It is important to ensure that all sections are filled out accurately to avoid delays in processing.
After submission, the request undergoes a review process. However, completion and submission of the form do not guarantee approval. The plan member will be notified of the decision, and this information will also be communicated to the prescribing doctor if requested.
Yes, if your request is denied, you have the right to appeal the decision made by Express Scripts Canada. The appeal process allows you to present additional information or clarification regarding your request.
The form requires various pieces of information, including:
All fields must be filled out accurately to prevent automatic denial of the request.
The plan member will receive notification regarding the approval or denial of their request. This communication ensures that the member is aware of the status of their medication coverage.
Yes, any fees related to the completion and submission of the Prior Authorization form are the responsibility of the plan member. It is important to be aware of these potential costs when seeking prior authorization for a medication.
Incomplete Information: One common mistake is leaving sections blank. Every field in the form is important for the approval process. If a section does not apply, write ‘N/A’ instead of leaving it empty.
Missing Attachments: Failing to include required documents can lead to automatic denial. Attach any provincial decision letters or other necessary documentation as specified in the form.
Incorrect Signatures: Ensure that both the plan member and the prescribing doctor sign the appropriate sections. An unsigned form will not be processed.
Not Following Submission Guidelines: Make sure to fax or mail the completed form to the correct address. Double-check the contact information for Express Scripts Canada to avoid delays.
The Express Scripts Prior Authorization form is an essential document for patients seeking coverage for certain medications. Alongside this form, several other documents often play a crucial role in the prior authorization process. Each of these documents serves a specific purpose, helping to ensure that the request is complete and that all necessary information is provided for review. Below is a list of commonly used forms and documents that accompany the Express Scripts Prior Authorization form.
Each of these documents plays a vital role in the prior authorization process, ensuring that patients receive the medications they need while adhering to the guidelines set forth by their insurance providers. By understanding the purpose of these forms, patients and healthcare providers can work together more effectively to navigate the complexities of medication coverage.
The Express Scripts Prior Authorization form shares similarities with the Insurance Claim Form, which is commonly used in healthcare settings. Both documents require detailed patient information, including personal identifiers and insurance details. They serve the purpose of obtaining approval for specific treatments or medications from insurance providers. Just as the Prior Authorization form necessitates a physician's input, the Insurance Claim Form often requires a healthcare provider's signature to validate the claim. Both forms aim to ensure that the prescribed services align with the patient's coverage and the insurer's policies.
Another document akin to the Express Scripts Prior Authorization form is the Medication Prior Authorization Request form used by various insurance companies. This form, like the Express Scripts version, is designed to collect information about the patient's medical condition and the necessity of the prescribed medication. Both forms include sections that allow healthcare providers to justify the need for a specific drug based on clinical criteria. The approval process for both documents hinges on the insurer's assessment of medical necessity, ensuring that patients receive appropriate care while managing costs.
The Patient Assistance Program Application is also similar to the Express Scripts Prior Authorization form. This document is intended for patients who require financial assistance to obtain their medications. Both forms necessitate patient and provider information and often require documentation of previous treatments or medications tried. The Patient Assistance Program Application seeks to demonstrate the need for support, just as the Prior Authorization form justifies the request for a specific medication based on clinical evidence. Each form plays a crucial role in facilitating access to necessary treatments for patients.
The Clinical Trial Enrollment Form shares characteristics with the Express Scripts Prior Authorization form, particularly in the information it collects about a patient's medical history and current treatments. Both documents require thorough detail to ensure that the patient meets specific criteria for participation or coverage. While the Prior Authorization form focuses on securing medication approval, the Clinical Trial Enrollment Form aims to assess eligibility for experimental treatments. In both cases, the information provided is essential for making informed decisions about patient care.
The Health Insurance Portability and Accountability Act (HIPAA) Authorization Form is another document that parallels the Express Scripts Prior Authorization form. Both forms involve the sharing of sensitive patient information, requiring explicit consent from the patient. The HIPAA Authorization Form allows healthcare providers to disclose patient information for various purposes, including treatment, while the Prior Authorization form seeks approval for a specific medication. Both documents emphasize the importance of patient consent and confidentiality in the healthcare process.
The Appeal Form for Denied Claims also exhibits similarities to the Express Scripts Prior Authorization form. When a prior authorization request is denied, patients may need to complete an appeal form to contest the decision. Both forms require detailed information about the patient's medical condition and the rationale for the requested treatment. In essence, they serve as mechanisms for patients to advocate for their healthcare needs, ensuring that their voices are heard in the decision-making process.
Lastly, the Prescription Drug Coverage Request Form resembles the Express Scripts Prior Authorization form in its purpose of obtaining approval for specific medications. This document typically requires information about the patient, the prescribed drug, and the clinical justification for its use. Both forms are integral to the process of ensuring that patients have access to necessary medications while navigating the complexities of insurance coverage. Each form reflects the need for careful documentation and adherence to established guidelines in the healthcare system.
When filling out the Express Scripts Prior Authorization form, keep the following guidelines in mind:
Avoid these common mistakes:
Many individuals believe that submitting the Express Scripts Prior Authorization form will automatically lead to approval for their medication. In reality, completion and submission of the form does not guarantee approval. The request must be reviewed and meet specific clinical criteria set by Express Scripts Canada.
Some people think that the responsibility lies solely with the prescribing doctor. However, the process requires both the plan member and the prescribing doctor to complete different sections of the form. The plan member must fill out Part A, while the doctor is responsible for Part B.
It is a common belief that submitting the prior authorization form is free of charge. In fact, any fees related to the completion and submission of the form are the responsibility of the plan member. This cost consideration is important for budgeting purposes.
Some individuals expect instant feedback after they submit their request. However, the notification regarding approval or denial does not happen immediately. The review process takes time, and plan members will receive a decision once it has been made.
People often think that if their request is denied, there is no recourse. This is incorrect. Plan members have the right to appeal the decision made by Express Scripts Canada, allowing them to seek reconsideration of the denial.
Here are some key takeaways about filling out and using the Express Scripts Prior Authorization form: