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/ / Pharmacy Prior Authorization Form Confidential Information Patient DOB Patient Name Patient ID Number Physician Name Specialty Phone Fax /naloxone DEA # Physician Address City State Drug.

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PET and CT scans, MRI, MRA, and nuclear cardiology. Prescribed pediatric extended care center (PPECC) and medical day care. Ambulance transportation to and from prescribed extended care center and medical day care.

Enroll Now Call 1-800-440-3989 (TTY users call 1-800-618-4225) for PA Enrollment Services. The HealthChoices enrollment specialists help people who are enrolled in the Medical Assistance program to choose a health plan. They have information about Keystone First and can answer your questions.

Dental benefits for members over age 21, who are eligible for dental benefits, are eligible for: 1 dental exam and 1 cleaning, every 6 months. Pulpotomies (removal of pulp) for pain relief. Re-cementing of crowns (re-gluing the crown).

Keystone First considers bariatric surgery to be clinically proven and, therefore, medically necessary when performed in accordance with: National Coverage Determination 100.1; Local Coverage Articles A52447, A53444, and A54923; and Local Coverage Determinations L35022 and L34576).

Keystone First is Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan serving more than 400,000 Medical Assistance recipients in southeastern Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.

Infertility diagnosis and treatment services, including sterilization reversals and related office (medical or clinical) drugs, laboratory, radiological and diagnostic and surgical procedures are not covered.

You are 21 years of age or older and begin receiving Medicare Part D (Prescription Drug Coverage). You go to a state mental health hospital. You may also become eligible for Community HealthChoices.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232