Express Scripts Prior Prescription (Rx) Authorization Form

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The Express Scripts Prior Prescription (Rx) Authorization Form is a document that is used by a patient’s prescriber in order to request that a certain non-preferred or non-formulary medication be covered under their insurance policy. It will be required of the prescriber that they provide justification for why they’re choosing to prescribe an alternative drug, one which is atypical and, usually, less cost effective for the insurance company. Previous treatments will need to be detailed, along with the negative results of said treatments which rationalize the healthcare provider’s decision. Express Scripts has created state-specific documents for each jurisdiction in which they operate.


How to Write

Step 1 – Download the appropriate prior authorization form from the list above. For the purposes of this tutorial, we will be detailing the General Request Form which can be used for the following states:

  • Arkansas
  • Illinois
  • Michigan
  • Oregon
  • Vermont


Step 2 – In the “Patient Information” window, enter the patient’s full name, identification number, date of birth, and home phone number. In the “Prescriber Information” window, the following will be required:

  • Prescriber name
  • Prescriber DEA/NPI
  • Phone number
  • Fax number
  • Address

Step 3 – Next, supply the diagnosis and the ICD code. The name of the requested medication can be provided as well along with the quantity and number of days the supply will last.

Step 4 – Other medication, treatment, or therapy that the patient has endured to treat their symptoms, and/or any other data deemed pertinent by the physician can be submitted in the paragraph field at this juncture.

Step 5 – The office contact name, phone number and the day’s date should be supplied. Print off the form, ensure that the prescriber’s signature is provided, then send the completed document via fax to 1 (877) 328-9799. If the medication is urgently needed, call: 1 (800) 753-2851.