If your pharmacist tells you your prescription "needs a prior authorization," it means Express Scripts needs more clinical information from your doctor before it can confirm your plan will pay for the medication. It's one of the most common reasons a prescription gets stuck at the pharmacy counter, and it catches most patients off guard because there's rarely any warning until they're standing at the register.
This guide walks through exactly how the process works at Express Scripts specifically — who can start it, which phone and fax numbers to use, what documents your doctor's office needs to have ready, how long it typically takes, and what your options are if the request comes back denied.
Express Scripts is a pharmacy benefit manager (PBM) owned by Evernorth, part of Cigna. It doesn't decide coverage rules on its own — it administers the prior authorization criteria set by your specific health plan, whether that's an employer plan, a Medicare Part D plan, a Medicaid managed care plan, or a marketplace plan. That distinction matters, because it explains why two Express Scripts members can have very different experiences with the exact same drug.
Table of Contents
- What Prior Authorization Actually Means
- Prior Authorization vs. Step Therapy vs. Formulary Exception
- Who Can Start the Request (And Who Can't)
- Phone, Fax & Portal: How to Submit a Request
- Required Information & Documents
- Step-by-Step: How the Process Works
- Decision Tree: Which Path Applies to You
- Approval Timelines by Submission Method
- Does Your Plan Type Change the Timeline?
- Does Income Affect Prior Authorization?
- Medications That Commonly Require Prior Authorization
- Renewing an Existing Authorization
- Common Mistakes That Cause Delays
- What to Do If You're Denied
- Pros and Cons of Each Submission Method
- Frequently Asked Questions
What Prior Authorization Actually Means
A prior authorization, or "coverage review," is a checkpoint your health plan puts in front of certain medications. Before Express Scripts will process the claim, it needs confirmation that the drug is medically necessary, prescribed for an FDA-approved or plan-approved use, and appropriate given your other medications and health history.
This isn't unique to Express Scripts — every major PBM (CVS Caremark, Optum Rx, Express Scripts) and every Medicare Part D plan uses some form of prior authorization. What differs is which drugs trigger it, which forms are required, and how the plan sponsor (your employer, state, or Medicare) has configured the rules.
| Feature | What It Means |
|---|---|
| Who Manages It | Express Scripts, on behalf of your specific health plan |
| Who Can Request It | Your prescriber (physician, NP, or PA) — not the patient directly |
| What It Checks | Medical necessity, diagnosis match, dosing, and safety |
| Typical Turnaround | Within two business days of complete submission |
| Cost to You | Free — there's no fee to request or process a coverage review |
Prior Authorization vs. Step Therapy vs. Formulary Exception
These three terms get used interchangeably, but each one triggers a slightly different review path at Express Scripts. Knowing which applies to your situation helps you and your prescriber submit the right paperwork the first time.
| Review Type | When It Applies | What Prescriber Must Show |
|---|---|---|
| Prior Authorization | Drug is on your plan's PA list (common for specialty drugs, GLP-1s, biologics) | Diagnosis, medical necessity, appropriate dosing |
| Step Therapy | Plan requires trying a preferred, lower-cost drug first | Proof the preferred drug was tried and failed, or is contraindicated |
| Formulary / Coverage Exception | Drug isn't on your plan's formulary at all | Why formulary alternatives aren't appropriate for you |
| Quantity Limit Exception | Requested dose or supply exceeds the plan's default limit | Clinical rationale for the higher quantity or dose |
Same form, different box. Express Scripts' general request form is used for all four review types above — your prescriber simply checks the relevant reason. If you were told to request a "step therapy exception," that's still handled through the standard prior authorization channel, not a separate process.
Who Can Start the Request (And Who Can't)
This is the single most misunderstood part of the process. Patients frequently call Express Scripts hoping to file the paperwork themselves — but the clinical review requires information that only a licensed prescriber's office can provide.
- Your prescriber's office submits the clinical request (by phone, fax, or ePA)
- You can call to check the status of a request already in progress
- You can view the status online after logging into your Express Scripts account
- You can follow up with your prescriber's office if they haven't submitted yet
- You cannot personally submit the clinical portion of a prior authorization
- You cannot bypass the review by calling and requesting an exception yourself
- You cannot get a decision faster by calling repeatedly without new information
Phone, Fax & Portal: How to Submit a Request
Express Scripts gives prescribers three main channels. Electronic prior authorization is the fastest and is used for more than half of all requests Express Scripts receives each month.
| Channel | Contact / Access Point | Best For |
|---|---|---|
| Phone (verbal PA) | 1-800-753-2851 | Straightforward requests when ePA isn't set up |
| Fax — general request form | 1-877-328-9660 | Step therapy exceptions, coverage determinations, appeals |
| Electronic PA (ePA) | CoverMyMeds, Surescripts, or EviCore by Evernorth | Fastest option — some decisions return within minutes |
| Patient customer service | 1-800-282-2881 | Checking status, general benefit questions (not filing a PA) |
| Member ID card / account help | 1-855-612-3121 | Replacing an ID card or account access issues |
State-specific forms exist. Several states — including California, Illinois, Texas, Massachusetts, Colorado, and New York — require their own standardized prior authorization forms rather than the general request form. Your prescriber's office should confirm which form applies before faxing.
Required Information & Documents
Missing clinical detail is the most common reason a request stalls. Before your appointment, it helps to know what your doctor's office will need to include.
| Information | Why It's Needed |
|---|---|
| Patient name, date of birth, member ID | Matches the request to your specific plan |
| Prescriber name, NPI, and contact information | Confirms a licensed provider is making the request |
| Diagnosis code (ICD-10) | Confirms the drug matches an approved use |
| Medication, strength, and dosing frequency | Confirms the exact request being reviewed |
| Prior medications tried (for step therapy) | Shows preferred alternatives were attempted or contraindicated |
| Relevant labs or clinical notes (for specialty drugs) | Supports medical necessity for higher-cost therapies |
Step-by-Step: How the Process Works
Your pharmacist flags the prescription
At the pharmacy counter, or often before you even arrive, the claim comes back showing a prior authorization is required. You'll typically get a text, call, or app notification.
Contact your prescriber's office
Let them know a coverage review is needed. Most prescriber offices have a staff member who handles prior authorizations regularly and already knows the process.
Prescriber submits the request
Using ePA, phone, or fax, your prescriber's office sends the diagnosis, medication details, and supporting clinical information to Express Scripts.
Express Scripts reviews the request
A clinical reviewer checks the submission against your plan's coverage criteria. An AI-assisted tool may help surface relevant clinical history, but Express Scripts states that coverage decisions themselves are made by human reviewers, not the AI tool.
You and your prescriber are notified
The decision — approved, denied, or withdrawn — is sent to both you and your prescriber. You can also check status anytime by logging into your account.
Your pharmacy fills the prescription
Once approved, the claim processes normally at retail or through Express Scripts Pharmacy home delivery, depending on how your prescription was routed.
Decision Tree: Which Path Applies to You
Step 1: Has your pharmacy told you a prior authorization is required?
✔ Yes → Continue to Step 2.
✖ No → No action needed; your prescription can be filled normally.
Step 2: Has your prescriber's office already submitted the request?
✔ Yes → Continue to Step 3.
✖ No → Call your prescriber's office and ask them to submit via ePA, phone (1-800-753-2851), or fax (1-877-328-9660).
Step 3: Has it been more than two business days since submission?
✔ Yes → Call 1-800-282-2881 or check your online account for status; ask your prescriber's office if additional information was requested.
✖ No → Wait — most reviews resolve within this window.
Step 4: Was the request denied?
✔ Yes → Move to the appeal, peer-to-peer review, or step therapy exception process.
✖ No → You're approved — your pharmacy can now process the claim.
Approval Timelines by Submission Method
| Submission Method | Typical Timeline |
|---|---|
| Electronic PA (ePA) — complete submission | Minutes to a few hours |
| Phone (verbal PA) — complete submission | Same day to two business days |
| Fax — complete submission | Two to three business days |
| Any method — incomplete submission | Delayed until the missing information is received |
| Appeal after a denial | Several business days, longer for external review |
The two-day window only starts once information is complete. Express Scripts' own guidance is that nearly all coverage reviews are completed within two business days — but that clock resets every time the reviewer has to go back to your doctor's office for missing details. A clean, complete first submission is the single biggest lever you have over your own timeline.
Does Your Plan Type Change the Timeline?
Express Scripts administers plans across several markets, and each one layers its own regulatory deadlines on top of the standard process.
| Plan Type | Regulatory Backstop |
|---|---|
| Employer-sponsored commercial plan | Set by the plan sponsor's contract; Express Scripts targets two business days |
| Medicare Part D | Federal rules generally require 72 hours for standard requests, 24 hours for expedited |
| Medicare Advantage, Medicaid managed care, CHIP, Marketplace plans | Newer CMS interoperability rules (finalized under CMS-0057-F) require faster standardized turnaround starting in 2026, though specific deadlines vary by request type |
| State Medicaid (fee-for-service) | Varies by state; some states publish their own required timeframes |
If your situation is urgent — for example, you're out of a medication with no safe substitute — ask your prescriber's office to mark the request as expedited. Expedited reviews are decided faster than standard ones, though "expedited" has a specific clinical definition and isn't automatically available for every request.
Does Income Affect Prior Authorization?
No. This is a common point of confusion because patients often research prior authorization and manufacturer patient assistance programs at the same time. They are not the same thing, and only one of them has income rules.
| Program | Income Requirement? | What It Actually Does |
|---|---|---|
| Express Scripts Prior Authorization | No income requirement | Clinical review of medical necessity — approves or denies coverage under your existing plan |
| Manufacturer Patient Assistance Programs | Yes — typically 200%–400% of the Federal Poverty Level | Provides free or discounted medication to uninsured/underinsured patients |
| Medicare Extra Help (Low Income Subsidy) | Yes — income and asset limits apply | Reduces Part D premiums, deductibles, and copays |
| State Pharmaceutical Assistance Programs | Yes — varies by state | Supplemental drug coverage for eligible state residents |
If cost, not coverage, is the real problem: a prior authorization approval doesn't automatically make a drug affordable — it just means your plan will apply its normal cost-sharing. If the copay is still too high once approved, look into a manufacturer savings card, our Drug Price Checker for cash-pay comparisons, or a GoodRx vs. Inside Rx comparison before assuming the medication is out of reach.
Medications That Commonly Require Prior Authorization
Every plan's list is different, but certain drug categories trigger a coverage review far more often because of cost, safety monitoring needs, or a crowded field of lower-cost alternatives.
| Drug Category | Example Medications | Why PA Is Common |
|---|---|---|
| GLP-1s (diabetes / weight management) | Ozempic, Wegovy, Zepbound, Mounjaro | High cost; diagnosis-specific approval criteria |
| Specialty biologics | Humira, Enbrel, Stelara, Skyrizi | Very high cost; step therapy commonly required |
| Oncology medications | Oral chemotherapy and targeted therapies | Diagnosis-specific dosing and safety monitoring |
| Insulins (select products) | Newer analog insulins | Formulary alternatives often preferred first |
| Certain brand-name drugs with generic equivalents | Varies by plan formulary | Plan encourages trying the generic first |
| High-quantity or high-dose prescriptions | Varies by drug | Exceeds the plan's default quantity limit |
If your medication is a GLP-1 or specialty biologic and the coverage review comes back denied, our insulin savings programs guide and our broader patient assistance program directory cover manufacturer-side alternatives worth exploring in parallel.
Renewing an Existing Authorization
Prior authorizations aren't permanent. Most are approved for a set period — commonly six to twelve months, depending on the drug and plan — after which your prescriber needs to submit updated clinical information.
- Ask your prescriber's office when your current authorization expires; it's often noted in your Express Scripts online account.
- Start the renewal request before the expiration date to avoid a gap in coverage.
- Renewals still require updated clinical justification — a lapsed authorization is treated as a new request, not an automatic extension.
- If your diagnosis, dosing, or treatment plan changed since the original approval, make sure your prescriber's office updates the record accordingly.
Renewal lapses are a common source of pharmacy-counter surprises. A medication that was covered for the past year can suddenly show as "not covered" the moment the authorization period ends, even if nothing about your treatment has changed. Set a reminder a few weeks before the anniversary of your original approval.
Common Mistakes That Cause Delays
- □ Prescriber's office assumes the patient must file the request.
- □ Diagnosis code doesn't match the medication being requested.
- □ Prior therapy history is missing for a step therapy exception.
- □ Wrong state-specific form used, or general form faxed to the wrong number.
- □ Request submitted for the wrong dose or quantity versus the actual prescription.
- □ Patient calls repeatedly for status updates instead of confirming the prescriber's office has responded to an information request.
- □ Renewal submitted after the existing authorization already expired.
Nearly all delays trace back to incomplete clinical documentation, not a slow reviewer. The fastest fix is usually a direct call between your prescriber's office and the Express Scripts prior authorization line to confirm exactly what's missing.
What to Do If You're Denied
A denial is a starting point, not a dead end. Most denials fall into a handful of categories, each with a specific next step.
| Reason for Denial | What It Means | Next Step |
|---|---|---|
| Doesn't meet plan's clinical criteria | Diagnosis or history doesn't match plan rules | Ask prescriber to submit additional clinical documentation or appeal |
| Step therapy not completed | Preferred alternative wasn't tried first | Either try the preferred drug or document why it's inappropriate |
| Incomplete submission | Missing required fields or documentation | Resubmit with complete information |
| Non-formulary medication | Drug isn't covered under any circumstance on this plan | Request a formulary exception or discuss covered alternatives |
Your Appeal Options
- Internal appeal: Your prescriber or you can request Express Scripts reconsider the decision, typically with additional clinical documentation.
- Peer-to-peer review: Your prescriber can request a direct conversation with the plan's clinical reviewer to discuss your case.
- Step therapy exception: If you already tried the preferred alternative, make sure that history was documented and resubmitted.
- External review: If the internal appeal is also denied, many plan types allow an independent third-party review — ask your plan or Express Scripts what applies to your coverage.
While you appeal, ask about a bridge supply. Some prescribers can write a short-term prescription for a retail pharmacy pickup while the appeal is pending, so you're not without medication during the review. See our patient assistance program guide if a longer-term affordability gap remains even after approval.
Pros and Cons of Each Submission Method
| Method | Pros | Cons |
|---|---|---|
| Electronic PA (ePA) | Fastest option; some decisions in minutes; documentation stored in one place | Requires prescriber's EHR or portal to support ePA |
| Phone (1-800-753-2851) | Direct, real-time conversation; good for simple, clear-cut cases | Requires prescriber's office to have time available; no written record unless followed by fax |
| Fax | Works for complex cases needing attached clinical notes; required for some state forms | Slowest method; risk of illegible or incomplete faxes |
Bottom Line
Express Scripts prior authorization exists to confirm a medication is medically necessary and appropriate before your plan covers it — it isn't a punishment, and it isn't optional paperwork you can skip. The process moves fastest when your prescriber's office submits electronically with complete clinical information the first time, and when you follow up proactively rather than waiting to find out at the pharmacy counter that something is missing.
If you're denied, treat it as a documentation problem to solve, not a final answer — appeals, peer-to-peer reviews, and step therapy exceptions resolve a large share of initial denials. And if the real issue turns out to be cost rather than coverage, that's a separate conversation involving savings cards, patient assistance programs, or a pharmacy price comparison.
Need to start or check a prior authorization?
Call Express Scripts at 1-800-753-2851 for verbal prior authorization, or 1-800-282-2881 for general patient customer service and status checks.
Go to Express Scripts → See Required DocumentsFrequently Asked Questions
Patients and prescribers can call Express Scripts at 1-800-753-2851 to submit or check on a verbal prior authorization request. General patient customer service, for questions unrelated to a coverage review, is 1-800-282-2881.
Express Scripts states that nearly all coverage reviews are completed within two business days once your doctor's office submits complete clinical information. Electronic prior authorization requests can sometimes be decided within minutes, while incomplete or faxed requests can take longer.
No. Prior authorization requests must come from your prescriber, since the review requires clinical information only your doctor's office can provide, such as your diagnosis and prior treatments tried. You can call to check status, but you can't initiate the clinical review yourself.
Completed general request forms and Benefit Coverage Request Forms are commonly faxed to 1-877-328-9660. Several states use their own standardized forms with separate fax numbers, so your prescriber's office should confirm the correct form before submitting.
You can request a formal appeal, ask your prescriber to request a peer-to-peer review with the plan's clinical reviewer, or ask about a step therapy exception if you already tried the preferred alternative. If the internal appeal is also denied, you may be entitled to an external review depending on your plan type.
No. Prior authorization is a clinical coverage review based on your diagnosis, prior treatments, and plan rules — it has no income requirement. Income limits apply to separate programs, such as manufacturer patient assistance programs and Medicare Extra Help, not to the prior authorization process itself.
Log in to your Express Scripts account and go to Prior Authorizations under Prescriptions to see the current status. You can also call 1-800-282-2881 for patient customer service or 1-800-753-2851 for the prior authorization line directly.
This usually means your plan's formulary or utilization management rules changed, often at the start of a new plan year. It's not necessarily a reflection of anything about your specific prescription — the same trigger applies to everyone on that plan taking that drug.
Your pharmacist can flag that a prior authorization is needed and often notifies your prescriber's office automatically, but the clinical request itself still has to come from your prescriber, since only they can supply the required diagnosis and treatment history.
Ask your prescriber's office to submit the request as expedited if your situation meets the clinical definition of urgent, such as being without a needed medication with no safe substitute. Expedited requests are prioritized ahead of standard ones. See our prior authorization guides for plan-specific expedited criteria.
How We Researched This Guide
References
- Express Scripts. Prior Authorization (PA) — Frequently Asked Questions.
- Evernorth. Prior Authorization Resources for Providers.
- Medicare.gov. Understanding Medicare Part D Coverage Determinations.
- Centers for Medicare & Medicaid Services. Medicare Part D Coverage Guidance.
- U.S. Food & Drug Administration. Drug Recalls.
Related Resources
Related Prior Authorization & Coverage Guides
- Prior Authorization Guides by Insurance Type
- Patient Assistance Programs: Full Directory
- Medicare Part D Explained: Coverage & Coverage Reviews
- Extra Help (LIS): Income Limits & How to Apply
- GoodRx vs. Inside Rx: Which Saves You More?
- Insulin Savings Programs: 2026 Guide
- Manufacturer Savings Cards Explained
- Drug Price Checker: Compare Cash Prices Near You
Editorial Policy: Refill Relay content is researched using publicly available PBM and manufacturer materials, federal coverage guidance, and standard industry application practices. Every article is reviewed for clarity, accuracy and usefulness before publication.