Get Universal Pharmacy Oral Prior Authorization Form ... - Keystone First

This guide provides step-by-step instructions on filling out the Universal Pharmacy Oral Prior Authorization Form for Keystone First. Follow the procedure to ensure that all necessary information is accurately submitted.

Follow the steps to complete the form accurately.

1. Use the ‘Get Form’ button to access the Universal Pharmacy Oral Prior Authorization Form and open it for editing.
2. Begin with the patient’s information. Enter the patient's name, date of birth, and patient ID number in the designated fields.
3. Next, fill in the physician's details. Provide the physician's name, phone number, specialty, fax number, license number, and complete address including city, state, and zip code.
4. Proceed to the medication section. Specify the medication name and strength requested. Add the dosage directions for the medication.
5. Indicate the anticipated length of therapy by selecting the applicable duration from the options: □ Days, 3 Months, or 6 Months.
6. Document the diagnosis associated with the medication request. This helps in validating the need for the prior authorization.
7. List any preferred medications that have been tried or any previous therapies. Include details about the strength, frequency, and duration of these medications.
8. Provide any rationale or additional information that may be relevant to the review process of this prior authorization request.
9. Ensure the physician signs and dates the form. This signature confirms the request for the prior authorization.
10. Finally, save your changes and either download, print, or share the completed form as per your requirement. Return the form to PerformRx, Keystone First, or fax it to 1-215-937-5018 as indicated.

Complete your Universal Pharmacy Oral Prior Authorization Form online today to ensure timely processing of your request.