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.

3 Easy Steps

  • 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®.


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


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