Last Audited 6/28/2014

Express Scripts Forms

Form Number Revision Date

Form Name

(Links to Plan Source Library)

Internal Use


N/A N/A Prescription Mail Order Form RA  
NEMSTLC.CLF 3/1/2005 Prescription Drug Claim Form RA  
Click Here for link to Express Scripts website



Please be advised that the forms in the PlanSource Library are only as current as the forms on the carrier’s web sites.  More and more carriers are requiring a user ID and password to access the forms section of their site, so it may delay PlanSource access to updated forms.  To access the most up to date forms, users may need to register with the carrier to obtain a login. 


Please note:  Any form in the PlanSource Library that is coded "RA" means that we are unable to locate the form on the carrier's website.  You may need to contact your carrier representative or broker to obtain the most current form.

If you can't find the form that you're looking for, please contact your insurance broker or HR Administrator.