2018 Prior Authorization and Step Therapy Forms
For faster service, please call the ESI Prior Authorization Dept. at (844)-424-8886, 24 hours a day, 7 days a week, TTY users: (800) 716-3231. If complete information is provided, a decision will be rendered by the end of the phone call.
Fax Form Procedure:
Please fill out the form below and fax your request to Express Scripts at 1-877-251-5896.
A decision about whether SCAN will cover a Part D prescription drug can be a “standard” coverage determination (prior authorization) that is made within the standard timeframe typically within 72 hours. Turnaround times for non-formulary exceptions and tier exceptions are typically within 72 hours upon receipt of completed information. If incomplete information is given, then the turnaround time will be delayed up to 14 days. Once a decision has been made, Express Scripts will send a letter to the physician’s office and the member regarding the decision of the coverage determination.
To check the status of a coverage determination and exception request, please call Express Scripts at (844) 424-8886.
Express Scripts, Inc.
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
- Acyclovir Sodium Inj
- Afinitor Disperz
- Aminosyn 7% With Electrolytes®
- Aminosyn 8.5%-Electrolytes®
- Aminosyn II®
- Aminosyn II 8.5%-Electrolytes®
- Amphotericin B Inj