Blank Express Scripts Prior Authorization Form

1. 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 approval before it can be reimbursed. This process ensures that the medication is medically necessary and meets specific clinical criteria established by Express Scripts Canada.

2. Who is responsible for completing the form?

   Completion of the form involves two main parties: the plan member and the prescribing doctor. The plan member fills out Part A, providing essential personal and insurance information. Afterward, the prescribing doctor must complete Part B, which includes medical details relevant to the medication request.

3. What steps should I follow to submit the form?

   Submitting the form is straightforward and involves three easy steps:

   • Step 1: The plan member completes Part A of the form.
   • Step 2: The prescribing doctor fills out Part B.
   • Step 3: The completed form is then faxed or mailed to Express Scripts Canada.

4. What happens after I submit the form?

   After submission, the request will undergo a review process. It's 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 approved or denied. The prescribing doctor will also receive this information if requested.

5. Can I appeal a denial of my request?

   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 situation.

6. What criteria are used to determine approval?

   The approval decision is based on pre-defined clinical criteria, which primarily include Health Canada approved indications and evidence-based clinical protocols. This means that the medication must be deemed appropriate for your specific medical condition.

7. Are there any costs associated with completing the form?

   Yes, any fees related to the completion of the Express Scripts Prior Authorization form are the responsibility of the plan member. It is advisable to check with your healthcare provider or insurance carrier for any specific costs that may apply.

8. What information is required from the prescribing doctor?

   Part B of the form requires the prescribing doctor to provide detailed information about the patient’s medical condition, drug history, and the specific medication requested. This information is crucial for the approval process and must be completed thoroughly to avoid denial.

Filling out the Express Scripts Prior Authorization form can be a straightforward process, but there are common mistakes that can lead to delays or denials. Understanding these pitfalls can help ensure a smoother experience.

One major mistake is incomplete information. If any required fields are left blank, the request may be automatically denied. It’s essential to fill out every section carefully. If a section does not apply, write “N/A” instead of leaving it empty. This simple step can prevent unnecessary complications.

Another frequent error is failing to provide the necessary supporting documentation. When submitting the form, ensure that any required letters or documents, such as provincial decision letters, are attached. Without this documentation, the review process may be stalled or the request denied outright.

Some individuals overlook the importance of accurate patient information. Double-check that all details, including the patient’s name, date of birth, and insurance information, are correct. Errors in this section can lead to confusion and delays in processing the request.

Additionally, plan members sometimes neglect to confirm their insurance coverage status. Before submitting the form, verify whether the patient has primary coverage and if a reimbursement request has been submitted. This information is crucial for the approval process and should not be overlooked.

It is also common for people to misunderstand the authorization section. Ensure that the consent is signed and dated properly. This authorization is necessary for the group benefit provider to exchange personal information, and any oversight can lead to delays.

Another mistake involves the prescribing doctor’s section. It is vital for the physician to complete their part thoroughly. Missing information or signatures can result in an automatic denial. Encourage the doctor to review the form carefully before submission.

Lastly, some individuals fail to follow up after submission. Once the form is sent, it’s important to check on the status of the request. If there are any issues or if additional information is needed, being proactive can help resolve these matters quickly.

By being aware of these common mistakes and taking the time to fill out the form accurately, plan members can improve their chances of a successful prior authorization request.

When submitting an Express Scripts Prior Authorization form, there are several other documents that may be required to support the request. These documents help ensure that the review process is thorough and that all necessary information is provided for a timely decision. Below is a list of commonly used forms and documents that can accompany the Prior Authorization request.

• Patient Assistance Program Enrollment Form: This form is used to enroll patients in programs that provide financial assistance for medications. It typically requires patient information and details about the prescribed medication.
• Provincial Coverage Decision Letter: If a patient has applied for reimbursement under a provincial plan, this letter details the coverage decision. It must be attached if the drug was denied or approved by the provincial authority.
• Primary Insurance Reimbursement Request: This document outlines any requests made to the patient’s primary insurance for reimbursement of the medication. It should include the decision letter from the primary plan.
• Clinical Summary Report: A report from the prescribing physician that summarizes the patient's medical history, current condition, and the rationale for the prescribed medication. This can provide valuable context for the review process.
• Previous Treatment History: A detailed account of any prior therapies the patient has undergone, including reasons for discontinuation. This information can support the necessity of the requested medication.
• Lab Results: Relevant laboratory test results that provide evidence of the patient’s medical condition. This can include blood tests, imaging results, or other diagnostic information.
• Medication History: A comprehensive list of all medications the patient has tried in the past, including dosages and outcomes. This helps to establish the patient's treatment journey.
• Appeal Letter: If a previous request was denied, this letter outlines the reasons for the appeal and provides additional supporting information that may influence the decision.
• Specialist Referral Letter: A letter from a specialist who may have treated the patient, providing insights into the patient's condition and the need for the requested medication.
• Authorization for Release of Information: A signed document allowing healthcare providers to share necessary medical information with Express Scripts. This is crucial for compliance and to facilitate the review process.

Having these documents ready can significantly streamline the Prior Authorization process. Each piece of information contributes to a clearer understanding of the patient's needs and can help in achieving a favorable outcome. Prompt submission of all required documentation is essential to avoid delays in treatment.

• Prior Authorization Request Form: Similar to the Express Scripts form, this document also requires detailed patient information and a physician's input. It serves the same purpose of obtaining approval for specific medications before they can be reimbursed by insurance.
• Medication Prior Authorization Form: This form is used by various health insurance companies. Like the Express Scripts form, it collects patient and prescriber details and assesses the medical necessity of the requested medication.
• Insurance Claim Form: While primarily used for reimbursement after medication is received, this form can sometimes include prior authorization sections. It ensures that the insurance provider has all necessary information to process claims, similar to the Express Scripts form.
• Patient Assistance Program Application: This document seeks assistance for patients who cannot afford their medications. It requires similar personal and medical information, ensuring that the patient's needs are clearly communicated, much like the prior authorization process.
• Clinical Documentation Request: Often required by insurers, this document requests specific medical records to support a prior authorization request. It parallels the Express Scripts form in that it aims to provide evidence for the medical necessity of a prescribed drug.

When filling out the Express Scripts Prior Authorization form, it is essential to follow specific guidelines to ensure a smooth process. Here are four things you should and shouldn't do:

• Do: Complete all required sections accurately. Ensure that all information is filled in, as incomplete forms may lead to automatic denials.
• Do: Attach any necessary documentation. Include letters regarding provincial coverage decisions or prior authorization approvals when applicable.
• Don't: Leave any fields blank. If a question does not apply, indicate this by writing ‘N/A’ to avoid confusion.
• Don't: Submit the form without reviewing it. Double-check for any errors or omissions before faxing or mailing the form to Express Scripts Canada.

Following these guidelines can help facilitate the approval process for your medication request.

Misconceptions about the Express Scripts Prior Authorization form can lead to confusion and delays in medication approval. Here are ten common misunderstandings:

1. Only doctors can submit the form. Many believe that only prescribing doctors can handle the Prior Authorization form. In reality, the plan member must complete Part A before it is submitted by the doctor.
2. The form guarantees approval. Some individuals assume that submitting the form guarantees that the medication will be approved. However, completion of the form does not ensure approval; it must still meet specific clinical criteria.
3. Fees are covered by Express Scripts. It is a common belief that any fees associated with the form are covered by Express Scripts. In fact, any fees incurred are the responsibility of the plan member.
4. All medications require Prior Authorization. Not all medications require Prior Authorization. Only specific drugs, as determined by the insurance plan, are subject to this process.
5. Approval timelines are the same for all requests. Many people think that all requests are processed within the same timeframe. Approval timelines can vary based on the complexity of the request and the information provided.
6. Only the patient is notified of the decision. Some individuals believe that only the plan member receives notification of the approval or denial. The prescribing doctor will also be informed, if requested.
7. All information on the form is optional. It is a misconception that all fields on the form are optional. Mandatory fields must be completed; leaving them blank will result in automatic denial.
8. Once denied, there is no recourse. Some think that a denial is final. However, plan members have the right to appeal the decision made by Express Scripts Canada.
9. Submitting the form is the last step. Many believe that submitting the form is the end of the process. In fact, additional information may be required during the review process.
10. Language preference does not matter. Some individuals think that their language preference does not affect the process. However, indicating a preferred language can facilitate better communication during the review.

Understanding the Express Scripts Prior Authorization form is essential for plan members prescribed medications that require prior authorization. Here are key takeaways to ensure a smooth process:

• Plan members must complete the form and submit it for any medication requiring prior authorization.
• All fees associated with completing the form are the responsibility of the plan member.
• The process consists of three steps: the plan member fills out Part A, the prescribing doctor completes Part B, and the form is then faxed or mailed to Express Scripts Canada.
• Completion and submission of the form do not guarantee approval; reimbursement is contingent upon a review and approval by Express Scripts Canada.
• Approval decisions are based on predefined clinical criteria, which include Health Canada approved indications and evidence-based clinical protocols.
• Plan members have the right to appeal any denial made by Express Scripts Canada.
• Notification of approval or denial will be sent to both the plan member and the prescribing doctor, if requested.
• It is crucial to fill out all mandatory fields in the form; leaving any field blank may result in an automatic denial.
• Supplemental information can be provided to support the reimbursement request, enhancing the chances of approval.

Filling out this form accurately and completely is vital. Take action promptly to avoid delays in accessing necessary medications.