Free Express Scripts Prior (Rx) Authorization Form - PDFPrior Authorization ResourcesExpress Scripts 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the member's last name, first name, SCAN ID number, and date of birth in the designated fields.
3. Fill in the prescriber’s name, contact person, office phone, and office fax for easy communication.
4. Specify the medication and diagnosis clearly to ensure accurate processing.
5. In SECTION A, answer the questions regarding the diagnosis for treatment of relapsing forms of Multiple Sclerosis. If 'No', provide the diagnosis details.
6. Confirm if the prescription is written by a neurologist and document any relevant symptoms or information that may assist in the review.
7. Ensure that the physician signs and dates the form before submission.
8. Fax the completed form to 1-877-251-5896 as indicated at the bottom of page 1.

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