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Express scripts prior authorization form pdf

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The document is a Prior Authorization Form for the medications Nuvigil and Provigil, requiring patient and prescriber information, diagnosis details, medication requests, and clinical assessments to determine eligibility for coverage. It outlines specific conditions under which these medications may be prescribed and includes instructions for urgent requests and confidentiality notices.

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2014	4.8 Satisfied (266 Votes)
2011	4.4 Satisfied (180 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the phone number for Express Scripts 877 363 1303?

Call (877) 363-1303 and have your prescription bottle ready. A patient care advocate will work with your doctor to transfer your non-specialty medication to Express Scripts Pharmacy. For specialty medications, call (877) 882-3324 and have your prescription bottle ready.

What is the fax number for Express Scripts prior authorization form?

After the form has been completed, it can be faxed to Express Scripts at 1-877-251-5896 for review. Express Scripts will notify your doctor of the approval or denial within 48 hours of receipt of the prior authorization form. Electronic Prior Authorization.

What if prior authorization for medication is denied?

If your request for prescription coverage was denied, you have the right to ask for a redetermination (appeal) of our decision. If youre an Express Scripts member, log in to your account before filling out this form. Did the doctor requesting this appeal also prescribe the medication?

How do I appeal a prior authorization denial with Express Scripts?

You may also ask us for an appeal through our website at .Express-Scripts.com. Expedited appeal requests can be made by phone at 1.800. 935.6103, (TTY users can call 1.800. 716.3231), 24 hours a day, 7 days a week (including holidays).

Can you appeal a prior authorization denial?

Express Scripts prior authorization phone lines are open 24 hours a day, seven days a week, so a determination can be made right away. If the information provided meets your plans requirements, you pay the plans copayment at the pharmacy.

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What are prior authorization forms?

A prior authorization form will include information about you, your medical conditions, and your health care needs. Its important to fill out the form completely and accurately. Incomplete or incorrect information could delay your request or result in a denial.

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How to modify Express scripts prior authorization form for 2011 online

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What is the phone number for Express Scripts 877 363 1303?

What is the fax number for Express Scripts prior authorization form?

What if prior authorization for medication is denied?

How do I appeal a prior authorization denial with Express Scripts?

Can you appeal a prior authorization denial?

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What are prior authorization forms?

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