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This form is based on express scripts standard criteria. To be used only for prescriptions which are to. Web prior authorization request form. Web you may also ask us for a coverage determination by phone at 1.800.935.6103 or through our website at.
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Web prior authorization (pa) also known as a “coverage review,” this is a process health plans might use to decide if your. Web this form is based on express scripts standard criteria and may not be applicable to all patients; An express scripts prior authorization. To be completed and signed by the prescriber.