Express Scripts Prior (Rx) Authorization Form

Updated December 31, 2021

An Express Scripts prior authorization form is meant to be used by medical offices when requesting coverage for a patient’s prescription. The medical staff will need to fill out the form with the patient’s personal and medical details, as well the prescriber’s information, before delivering it to Express Scrips for review. For your convenience, we have provided the authorization form within this webpage which you can download and complete on your computer.

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How to Write

Step 1 – In “Patient Information”, provide the patient’s full name, ID number, date of birth, and phone number.

Step 2 – In “Prescriber Information”, provide the prescriber’s name, DEA/NPI, phone number, fax number, and full address.

Step 3 – Supply the patient’s diagnosis and ICD code in the appropriate fields.

Step 4 – Indicate which drug and strength is being requested. Also, specify the quantity and the supply needed (amount of days).

Step 5 – If the patient has tried other medications/therapies, indicate the reason(s) for failure and mention any other details related to this issue.

Step 6 – At the bottom of the page, have the prescriber give their signature as well as the date. Lastly, write the name of the medical office and the corresponding phone number.