Blank Express Scripts Prior Authorization PDF Template

1. What is the Express Scripts Prior Authorization form?

   The Express Scripts Prior Authorization form is a document required for any plan member who is prescribed a medication that needs prior authorization. This form must be filled out and submitted by following three steps: the plan member completes Part A, the prescribing doctor completes Part B, and the completed form is then faxed or mailed to Express Scripts Canada. This process is essential for obtaining coverage through a private drug benefit plan for those medications that require prior authorization.

2. How does the prior authorization process work?

   The process involves three main steps for completion and submission. Initially, the plan member is responsible for filling out Part A of the form. Subsequently, the prescribing doctor fills out Part B, which includes detailed medical and drug history information. Finally, the completed form should be sent to Express Scripts Canada either by fax or mail. Approval of the medication is not guaranteed and depends on meeting certain clinical criteria based on Health Canada's approvals and evidence-based clinical protocols.

3. Who is responsible for any fees associated with completing the form?

   All fees related to the completion of the Express Scripts Prior Authorization form are the responsibility of the plan member. It's important for members to be aware of potential costs that may be incurred in the process of obtaining prior authorization for prescribed medications.

4. What happens after the form is submitted?

   Once the form is submitted, it undergoes a review process where the decision to approve or deny the request is made based on specific clinical criteria linked to the medication's approved indications and supporting evidence. Both the plan member and the prescribing doctor will be notified of the decision. If the prescribing doctor has requested it, the decision can also be communicated via fax.

5. Is the plan member notified about the decision?

   Yes, the plan member will be notified about the outcome of their request. They will learn if their request for prior authorization has been approved or denied, ensuring transparent communication about their medication coverage eligibility.

6. What if the request for prior authorization is denied?

   If a request is denied, the plan member has the right to appeal the decision made by Express Scripts Canada. This means that there is an avenue available for members to seek reconsideration of the decision, possibly requiring the submission of additional supporting documents or clarification on the medical necessity of the medication.

7. Can additional information be submitted to support the drug reimbursement request?

   Yes, supplemental information supporting the drug reimbursement request is accepted and can be beneficial for the approval process. For example, for a first-time application, details on the severity or stage of the condition, previous therapies, and reasons for their cessation can be crucial. For a renewal, details on the clinical response to the requested drug are necessary. Providing comprehensive and detailed information can aid in the assessment and potential approval of the request.

1. Not fully completing all required sections: Plan members sometimes submit forms with incomplete sections. Parts A and B must be fully completed, including patient information, drug information, medical condition, and prescribing doctor's information. Leaving any mandatory field blank or not filling non-applicable fields with 'N/A' can automatically result in a denial.

2. Failing to attach necessary supporting documents: Essential documents, such as the provincial decision letter if the drug has been denied or approved under a provincial plan and any previous decision letters from primary plans, are often overlooked. This oversight can impact the review process negatively.

3. Not providing detailed medical condition and treatment history: In Section 2, for a first-time application, and Section 3, for a renewal, it is crucial to include detailed information about the patient's medical condition, treatment history, and clinical response. A summary or lack of specifics can hinder the approval process.

4. Mistakes in the authorization section: Some plan members forget to sign the authorization section, which gives consent for the exchange of personal information for the purpose of processing the request. This signature is vital for the form to be processed.

5. Incorrect submission method: The form must be faxed or mailed to the specified Express Scripts Canada addresses. Using incorrect or outdated contact information for submission can delay or prevent the form from being processed.

Ensuring each of these common mistakes is avoided can streamline the review process, potentially leading to a faster approval decision.

When dealing with the Express Scripts Prior Authorization form, it's important to collect and prepare additional forms and documents to ensure a smooth and efficient approval process. These supplementary documents are critical because they provide a more comprehensive view of the patient’s health status, their financial situation, and the medical necessity for the prescribed medication. Below, we'll explore some of these essential documents.

• Insurance Coverage Verification Form: This document is used to confirm the patient’s current insurance coverage, policy details, and benefits eligibility, which is vital for determining the reimbursement level for the prescribed medication.
• Medical History Record: A detailed record of the patient's medical history, including previous diagnoses, treatments, and outcomes, helps in making an informed decision regarding the necessity and safety of the requested medication.
• Doctor’s Prescription Note: A formal prescription from the prescribing healthcare professional that indicates the necessity of the medication can provide the clinical rationale behind the prior authorization request.
• Laboratory Test Results: Recent lab test results that support the need for the prescribed medication are often required to prove the medical necessity as per the clinical guidelines.
• Treatment Plan: A document outlining the planned course of treatment with the requested medication, including dosage, frequency, and duration, helps in assessing its expected benefits for the patient.
• Drug Formulary: A list from the insurance provider that includes medications that are covered under the patient's health plan can be useful to determine if the requested drug is preferred, non-preferred, or not covered at all.
• Appeal Letter Template: In case of prior authorization denial, having an appeal letter template ready can expedite the process of contesting the decision, providing another opportunity for approval.
• Financial Assistance Program Application: For patients who might face financial challenges in accessing their medication, applications for financial aid or patient assistance programs can be critical.

Having these documents alongside the Express Scripts Prior Authorization form can streamline the approval process, reducing delays and increasing the chances of a favorable outcome. It's crucial for patients and healthcare providers to collaborate closely, ensuring that all required information is accurate, up-to-date, and readily available. This comprehensive approach helps in navigating the complexities of medication approvals, ultimately aiding in the patient's timely access to necessary treatments.

• The Medicare Prior Authorization Form is similar because it also requires both patient and prescribing physician information for medication covered under Medicare. This form, like the Express Scripts Prior Authorization form, is a prerequisite for receiving specific medications not automatically covered under the plan’s formulary.

• The Pharmacy Benefit Management (PBM) Prior Authorization Request Form shares similarities as it involves a request process where the physician must provide patient-specific details and medical justification for the prescribed medication, much like the Express Scripts form lays out specific requirements for prescription approval.

• Medical Insurance Prior Authorization Form operates on the same basic principle - a requirement for prior approval from the insurance company before certain medications or treatments are covered. It necessitates the completion of detailed patient and medication information by the healthcare provider.

• The Specialty Pharmacy Medication Request Form is similar in its requirement for specific medication requests to be fully documented and justified by the prescribing physician. This often includes patient history and the reason alternative treatments have been ineffective, parallel to the detailed clinical information requested in Express Scripts' form.

• A Pre-Treatment Authorization Form used by dental or medical offices before specific treatments can begin also mirrors this form. It requires healthcare providers to submit treatment plans and justifications to insurance for coverage approval, focusing on the pre-approval process.

• The Health Reimbursement Arrangement (HRA) Request Form is similar in its function to verify eligibility for reimbursement of medical expenses, including medications. This form often requires detailed medical information and anticipated costs, akin to prescription drug prior authorization forms.

• The Medical Device Prior Authorization Form shares similarities in that it is designed to obtain permission before issuing certain medical devices to patients. Required information typically includes medical necessity and patient condition, much like medication prior authorization forms.

• An Insurance Claim Form is similarly detailed, requiring comprehensive patient information, diagnosis, and treatment details for reimbursement purposes. While serving a slightly different end, it similarly involves thorough documentation for financial approval.

• The Medication Therapy Management (MTM) Program Enrollment Form parallels the prior authorization form in its objective to tailor patient medication plans for efficacy and safety, requiring detailed patient medication history and current treatments for program eligibility.

When filling out the Express Scripts Prior Authorization form, there are specific steps and precautions you should take to ensure the process goes smoothly. Below are the dos and don'ts that can help guide you through this process.

Do:

• Make sure the plan member completes Part A of the form thoroughly. Double-check that all personal information fields, such as first name, last name, insurance carrier name/number, group number, client ID, date of birth, relationship, language, gender, address, email, and all telephone numbers are correctly filled.
• Ensure that the prescribing doctor fills out Part B accurately, providing detailed information about the medical condition, the requested drug, and its administration, including any previous therapies and the current Health Canada approved indication(s) for the drug.
• Attach any necessary supporting documents, such as a provincial decision letter or the primary coverage decision letter, if applicable. This will help in the evaluation of your prior authorization request.
• Review the completed form for any missing information or sections that might have been inadvertently skipped. Missing information can lead to an automatic denial of the request.

Don't:

• Leave any mandatory fields blank in either part of the form. If a section does not apply, be sure to fill it with 'N/A' instead of leaving it empty to avoid automatic denial.
• Forget to sign and date the form where required. A plan member’s signature is needed to authorize the exchange of personal information for the purposes of processing the request.
• Omit any relevant medical information or history that could support the prior authorization request, especially when detailing the medical necessity of the drug and any previous therapies tried.
• Delay in submitting the completed form to Express Scripts Canada via fax or mail. A timely submission is crucial, especially if the medication is needed urgently.

There are several misconceptions about the Express Scripts Prior Authorization form that need clarification to ensure that both patients and prescribers have a clear understanding of the process. Here are six common misconceptions:

• Any fees associated with completing the form are charged by Express Scripts Canada. In reality, any fees related to the completion of the form are the responsibility of the plan member. This can often be misunderstood, implying that Express Scripts or the prescribing doctor charges additional fees for the authorization process.
• Submitting the form guarantees approval. Just because the form is completed and submitted doesn’t guarantee that the medication will be approved for coverage. The decision is based on pre-defined clinical criteria, primarily focusing on Health Canada approved indications and evidence-based protocols. This is a critical piece of information as it sets realistic expectations for plan members.
• The process is lengthy and complicated. The form outlines three clear steps for submission, suggesting an effort to make the process as straightforward as possible. While it does involve multiple parties—the plan member, the prescribing doctor, and Express Scripts Canada—the steps are designed to be easy to follow.
• There is no recourse if a request is denied. Plan members have the right to appeal the decision made by Express Scripts Canada. This is an important right that ensures plan members are not left without options if their initial request is not approved.
• Prior Authorization is only for rare or expensive drugs. While it's common for expensive or specialty medications to require prior authorization, the criteria include a range of factors, including safety concerns and potential for misuse, not solely the cost of the medication.
• Doctors are solely responsible for the submission process. The process begins with the plan member who must complete the first part of the form before taking it to their doctor. The prescribing doctor completes the second part and then the form is faxed or mailed to Express Scripts Canada by either the doctor or the plan member. Responsibility is shared between the patient and the prescribing physician, highlighting a collaborative aspect of the process.

Understanding these misconceptions can help demystify the prior authorization process with Express Scripts Canada, making it easier for patients and healthcare providers to navigate it effectively.

Filling out and using the Express Scripts Prior Authorization form requires a thorough understanding to ensure that medications are covered under your plan. Here are key takeaways to guide plan members and prescribing doctors through the process:

• Step-by-Step Completion: The form is divided into a clear, three-step process. Initially, the plan member is responsible for completing Part A. Subsequently, the prescribing doctor must complete Part B. Finally, the completed form should be sent to Express Scripts Canada either by fax or mail. Understanding each part's requirements is crucial for a successful submission.
• Financial Responsibility: It is important for plan members to note that any fees associated with the completion of this form fall under their responsibility. This information sets clear expectations and helps plan members prepare for any potential costs involved in the process.
• Approval is Not Guaranteed: Submission of the prior authorization form does not automatically result in approval. This decision is made based on pre-defined clinical criteria and Health Canada approved indications. Being aware of this can help manage expectations and prepare for alternative steps if the request is denied.
• Right to Appeal: If a request is denied, plan members have the right to appeal Express Scripts Canada's decision. This is a critical point for plan members and prescribing doctors to understand, as it provides an additional course of action in the pursuit of gaining approval for necessary medications.

It is imperative for both plan members and prescribing doctors to pay close attention to detail when completing the form, and to comply with all specified requirements and steps. Doing so maximizes the chances of approval and ensures that the process proceeds as smoothly as possible.