Express Scripts General Request Form (Prior Auth)

Evernorth tells prescribers to use this one-page fax form for prior authorization, for a coverage determination such as a step therapy exception, or for an appeal of a coverage decision when the patient's drug benefit runs through Express Scripts. It asks for the diagnosis, drug, quantity and prior therapies. Express Scripts reviews it against its standard criteria, and the patient's plan may add drug-specific questions before deciding.

Who completes it

The prescriber completes and signs the whole form, including the required DEA or NPI number, and names an office contact with a phone number. The patient and pharmacy have no section on it.

How to fill it in

Header: standard criteria, fax number and urgent line

The top of the form says it is based on Express Scripts standard criteria and may not apply to every patient, and that certain plans and situations require information beyond what the form asks for. It points to express-scripts.com/pa for additional forms, prints the fax number for completed forms, and gives a phone number for URGENT requests. Check first whether Evernorth posts a state form for the patient's plan.

Patient Information

Enter the patient's first name, last name, patient ID number, date of birth and phone number. Unlike many payer forms, this block asks for no address, sex or group number, so the patient ID and date of birth are what link the request to the patient's Express Scripts coverage. Copy the ID from the prescription benefit card.

Prescriber Information

Give the prescriber's name, DEA or NPI number, phone, fax, address, state and ZIP code. The DEA/NPI field is the only one on the form labeled required. List a phone and fax where the office can receive the plan-specific questions that the footer warns may be needed to complete the prior authorization process.

Diagnosis and ICD Code

Write the diagnosis and its ICD code on the line below the two information blocks. This is the only place on the form for the indication, so name the specific condition being treated and make sure it matches the reasons given in the medications and therapies section further down.

Drug and strength requested, Quantity Requested for days supply

Name the drug and strength being requested, then the quantity and the number of days it should last, as printed: Quantity Requested, for, days supply. When the request concerns a quantity limit, these two numbers show the reviewer exactly what is being asked for, so give the full amount the patient needs.

Other Medications/Therapies tried and reason(s) for failure

This open section holds the clinical case: other medications or therapies tried, the reasons each failed, and any other information the physician considers important to the review. For a step therapy exception or an appeal, name each prior drug with its dose, how long it was used and the outcome or intolerance. Evernorth says its prior authorization criteria are available upon request, which helps target what to document.

Prescriber Signature and Office Contact

The prescriber signs and dates the form, and the office lists a contact name and phone number. The footer explains that additional questions may be required depending on the patient's plan and that questions about the process go to the prior authorization team at the number at the top. It also states that prior authorization of benefits is not the practice of medicine or a substitute for the treating physician's judgment.

Common mistakes

Leaving the DEA/NPI field blank, even though it is the one field on the form marked required.
Faxing an urgent request, when the form says to call the urgent line printed at the top of the page.
Using the general form in a state where Evernorth posts its own form, such as Illinois, which the page lists as a required form.
Sending this version for WLP (Anthem or Elevance) members, when the posted file name says it is not for WLP requests.
Treating the form as the whole review; it states that certain plans and situations require more information, and plan-specific questions may follow.

Submitting and payment

How to submit it: Fax the completed form to the number printed at the top, and call the urgent line shown there instead for urgent requests. Evernorth encourages ePA through EviCore by Evernorth, Surescripts or CoverMyMeds and also takes verbal prior authorization requests by phone.

Good to know

The posted file is labeled not for WLP (Anthem and Elevance) requests, so offices prescribing for those members should confirm the correct form before faxing.
Evernorth posts state fax forms for Arizona, California, Colorado, Illinois, Iowa, Kansas, Louisiana, Massachusetts, Nebraska, New Hampshire, New York, Oklahoma and Texas, plus one combined form for Arkansas, Michigan, Oregon and Vermont.
Express Scripts does not post drug-specific fax forms; drug-specific questions come through ePA or on request, and Evernorth says its prior authorization criteria are available upon request.
A request for a zero-copay ACA preventive drug goes on the separate Benefit Coverage Request Form, which asks for a clinical review of an alternative medication.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Form General Request Form

Official page PDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I use the Express Scripts General Request Form for an appeal?

Yes. Evernorth's prior authorization page says the General Request Form can be used to request a coverage determination, such as a step therapy exception, and to make an appeal asking Express Scripts to reconsider a coverage decision. Use the medications and therapies section to explain what was tried, why it failed and why the decision should change.

Is an NPI or DEA number required on the Express Scripts form?

Yes. The Prescriber Information block marks the DEA/NPI field as required, and it is the only field the form labels that way. The same block asks for the prescriber's name, phone, fax and address, and the office contact name and phone at the bottom give the prior authorization team someone to reach with follow-up questions.

How do I submit an urgent prior authorization to Express Scripts?

Call rather than fax. The form directs URGENT requests to the phone number printed beside the fax number at the top of the page, and Evernorth also accepts verbal prior authorization requests by phone. Electronic submission through EviCore by Evernorth, Surescripts or CoverMyMeds is the route Evernorth encourages for every request.

Does Cigna use the Express Scripts General Request Form?

For drugs, yes in practice. Cigna pharmacy prior authorizations run through Express Scripts (Evernorth), so drug requests for Cigna pharmacy members go to Express Scripts by ePA, by phone or on this fax form. Cigna's own medical precertification fax form is for medical services, not prescriptions.