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Prior Authorization & Step Therapy Forms

Category: Pharmacy

Where prior authorization is needed, please provide the information below.  Call the ESI Prior Authorization Department for faster service. If complete information is provided, a decision will be made by the end of the phone call.

Call:  1-844-424-8886, 24/7.  TTY users, call 1-800-716-3231.
Fax form below to: 1-877-328-9799

Coverage Determination Request Form

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 1-844-424-8886.

Express Scripts, Inc.
Attn: Medicare Reviews
P.O. Box 66571
St Louis, MO 63166-6571
Fax number: 1-877-328-9799

Physician Coverage Determination Form

2016 Prior Authorization and Step Therapy Forms

2016 Prior Authorization Criteria

2016 Step Therapy Criteria

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