Prior Authorization Forms

Certain medications may need approval from your insurance carrier before they are covered. A Prior Authorization Form must be submitted if the prescribed medication requires approval. Follow these simple steps in order to complete and submit a Prior Authorization form for review.

• Step 1 Patient completes Part A.
• Step 2 Prescribing physician completes Part B.
• Step 3 Fax or mail the completed form to Express Scripts Canada ® .

Fax

Express Scripts Canada
Clinical Services
1 (855) 712-6329

Mail

Express Scripts Canada Clinical Services
5770 Hurontario Street, 10th Floor,
Mississauga, ON L5R 3G5

Search Prior Authorization Forms

The following is a list of all medications on the Express Scripts Canada Prior Authorization Drug list. Please note that coverage eligibility for drugs listed on this page may vary depending on your plan design.

Eligibility for the products that are associated with a * symbol is limited to select benefit plans.

Accessible formats are available upon request to Human Resources.