Get Pharmacy Benefit Limit Exception Form - Keystone First

Filling out the Pharmacy Benefit Limit Exception Form for Keystone First is a crucial step in ensuring that individuals receive necessary medications that may exceed pharmacy benefit limits. This guide provides clear, step-by-step instructions to assist users in completing the form correctly and efficiently online.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Request Information' section. Provide your name, contact number, and email address to ensure proper communication.
3. In the 'Member Information' section, enter the member’s address. If there is a second address line, complete that as well.
4. Next, move to the 'Prescriber Information' section. Fill in the prescriber’s name and address, including the suite number if applicable.
5. For the 'Medical Information' section, list the medications requiring exceptions. For each medication, provide the drug name, strength, directions, ICD-9 or diagnosis code, quantity per month, and the number of refills if necessary.
6. Respond to the questions regarding the patient's health condition by selecting 'Yes' or 'No' and providing explanations and supporting documentation where applicable.
7. Indicate whether the exception is necessary to comply with Federal law and provide any supporting documentation to justify your request.
8. If the prescription requires prior authorization, be sure to state this and attach the relevant documentation as specified in the clinical review guidelines.
9. Sign the form in the designated 'Prescriber Signature' area and date it appropriately.
10. Once completed, save changes to the form. You can then download, print, or share the document as needed. Finally, fax the completed form along with required clinical information to the provided fax number or return it to the specified address.

Complete your Pharmacy Benefit Limit Exception Form online today to ensure your necessary medications are accessible.