The Express Scripts Prior Authorization form is a document that plan members must complete when prescribed a medication requiring prior authorization. This form ensures that the medication aligns with the clinical criteria set by Express Scripts Canada and is essential for receiving reimbursement through a private drug benefit plan. To initiate the process, plan members should fill out the form and submit it by clicking the button below.
The Express Scripts Prior Authorization form is an essential tool for plan members who need to obtain approval for certain medications. This process begins when a member is prescribed a drug that requires prior authorization. To initiate the request, the member must complete Part A of the form, providing personal information such as their name, insurance details, and contact information. Next, the prescribing doctor takes over by filling out Part B, which includes critical information about the patient's medical condition and the specific medication requested. Once both sections are completed, the form can be submitted via fax or mail to Express Scripts Canada. It's important to note that submitting this form does not guarantee approval; decisions are based on established clinical criteria and evidence-based protocols. Members will receive notification about the outcome, and if necessary, they have the right to appeal any denial. This straightforward process aims to ensure 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 an essential step for plan members who need approval for certain medications. Once the form is completed, it should be submitted to Express Scripts Canada for review. This process helps ensure that the medication prescribed is appropriate and covered under the member's plan.
After submission, you will be notified of the decision regarding your request. Remember, approval is not guaranteed, and you have the right to appeal if necessary.
What is the purpose of the Express Scripts Prior Authorization form?
The Express Scripts Prior Authorization form is used by plan members who have been prescribed medications that require prior authorization. This process ensures that the prescribed drug is medically necessary and meets the criteria set by the insurance provider. Completing this form is a crucial step in obtaining coverage for the medication through a private drug benefit plan.
Who is responsible for completing the form?
The completion of the form involves two parties: the plan member and the prescribing doctor. The plan member fills out Part A, which includes personal and insurance information. Then, the prescribing doctor completes Part B, providing necessary medical details about the patient’s condition and treatment history.
What are the steps to submit the Prior Authorization request?
Submitting the request involves three straightforward steps:
For fax submissions, use the number 1 (855) 712-6329. For mail, send it to Express Scripts Canada Clinical Services, 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5.
Is there a guarantee that my request will be approved?
No, completing and submitting the form does not guarantee approval. The request will be reviewed based on pre-defined clinical criteria, which include Health Canada approved indications and evidence-based clinical protocols. Only after this review can a decision be made regarding approval or denial.
How will I be notified about the decision?
Plan members will receive notification regarding the approval or denial of their request. Additionally, if requested, the prescribing doctor will also be informed of the decision via fax. This ensures that both parties are kept in the loop about the status of the authorization.
Can I appeal a denial decision?
Yes, if your request is denied, you have the right to appeal the decision made by Express Scripts Canada. The appeals process allows plan members to present additional information or clarify any misunderstandings regarding their request.
Are there any fees associated with submitting the form?
Yes, any fees related to the completion of the Prior Authorization form are the responsibility of the plan member. It is important to be aware of these potential costs when preparing to submit your request.
What information do I need to provide in the form?
In Part A, the plan member must provide personal information, including:
In Part B, the prescribing doctor must supply details about the medication requested, the patient's medical condition, and any previous treatments. This comprehensive information is essential for the approval process.
Filling out the Express Scripts Prior Authorization form can be a straightforward process, but many individuals make common mistakes that can delay their requests. One frequent error is not completing all required fields in Part A. Leaving any section blank can lead to an automatic denial of the application. It is essential to ensure every question is answered, even if the answer is "N/A" for non-applicable fields.
Another mistake is not providing accurate patient information. Double-checking details like the patient's name, date of birth, and insurance information is crucial. Any discrepancies can cause confusion and potentially result in a denial. Additionally, failing to attach necessary documents, such as the provincial decision letter or previous approval letters, can hinder the approval process.
Many people overlook the importance of the prescribing doctor's section in Part B. This part must be completed thoroughly by the physician. Incomplete information from the doctor can lead to delays or denials. It's also vital to ensure that the medical condition and drug history are detailed accurately, as this information is critical for the approval process.
Another common oversight is not indicating whether the request is for a first-time authorization or a renewal. Selecting the wrong option can lead to the form being processed incorrectly. It is important to follow the instructions carefully to ensure the right sections are filled out based on the type of request.
Plan members often forget to sign and date the authorization section. Without a signature, the form may be deemed invalid, causing further delays. It's a simple step that can easily be overlooked but is necessary for the request to be processed.
When it comes to the medical condition, some applicants fail to provide sufficient details about the severity or stage of the condition. Providing clear and comprehensive information helps the reviewer understand the necessity of the requested medication. Vague descriptions can lead to confusion and potential denial.
Another mistake is not specifying the site of drug administration. This detail is essential and should be clearly indicated to avoid misunderstandings about where the treatment will occur. Whether it’s at home, a doctor’s office, or a hospital, this information is critical for the approval process.
Individuals sometimes neglect to mention any previously tried therapies. This information is important for the reviewer to assess the necessity of the new medication. Not providing this context can result in a lack of understanding of the patient's treatment history, leading to a denial.
Lastly, failing to keep a copy of the submitted form can be a significant oversight. Having a record of what was submitted can help if there are any questions or if an appeal is necessary. It is always advisable to maintain a personal copy for reference.
By being mindful of these common mistakes, plan members can streamline their experience with the Express Scripts Prior Authorization form and increase their chances of a successful request.
When submitting an Express Scripts Prior Authorization form, several other documents may be required to support the request. These documents help provide additional context and information needed for the approval process. Below is a list of commonly used forms and documents that often accompany the Prior Authorization form.
Gathering and submitting these documents along with the Express Scripts Prior Authorization form can significantly enhance the chances of approval. Each piece of information plays a vital role in demonstrating the necessity and appropriateness of the prescribed medication.
When filling out the Express Scripts Prior Authorization form, there are several important dos and don'ts to keep in mind. These guidelines can help ensure that your request is processed smoothly and efficiently.
By following these guidelines, you can help facilitate a smoother process for obtaining prior authorization for necessary medications.
Here are 10 common misconceptions about the Express Scripts Prior Authorization form, along with clarifications for each:
Key Takeaways for Completing the Express Scripts Prior Authorization Form: