Express Scripts Prior Authorization Fax Form | PDF

General Fax Form – Send to 1-877-329-3760

Request Script Online

1.800.753.2851

All Forms | Drug Specific

The Express Scripts prior authorization fax form allows prescribers management over a patient’s prescription drug use and may request scripts by telephone, online, or fax.

How to Request a Script

A prescription may be requested in any of the following ways;

• Fax – 1-877-329-3760
• Online – By logging-in and making the request.
• Telephone – 1.800.753.2851

Sources

• www.express-scripts.com/services/physicians/medcopa/docs/General_Request_Form_F14.pdf