Medical Necessity & Prior Authorization Forms/Criteria

Your provider (the prescriber) must obtain authorization for some prescription medications to be filled. Listed below are the Quantity Limits, Prior Authorization and Medical Necessity Forms and Criteria you will need in order to request drugs that require authorization. You do not need to submit multiple forms because authorization approvals apply to both the mail-order and retail network pharmacy options.

To submit a request:

1. Select and print the proper form(s) from the listings below by scrolling down and clicking on the appropriate pdf icon. Drugs are listed by AHFS Therapeutic Class, Brand Name, and Generic Name.
2. Have your provider fill out the form completely.
3. Follow the directions on the completed form for delivery to Express Scripts, Inc.

If you are unable to find a particular form please forward a message to with your information and a ESI representative will be in contact with you shortly.

The forms are provided here in Adobe Acrobat. If you cannot view a file, please download the appropriate free plug-in from the Adobe Acrobat Reader link below:

Download Adobe Acrobat Reader

  Generic Medications
The pharmacy benefits program mandates substitution of generic drugs listed with an "A" rating in the current Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book) published by the FDA unless sufficient clinical justification from the prescriber is submitted. Prescribers may call 1-866-684-4488 to submit a request for a brand name drug to be dispensed in lieu of a generic.

Brand over Generic Prior Authorization Request Form

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AHFS Therapeutic Class   Brand Name   Generic Name   Medical Necessity Form Prior Authorization Form
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