Get Keystone Vip Choice Prior Authorization Form

Filling out the Keystone Vip Choice Prior Authorization Form online is a straightforward process designed to help you request coverage for prescription drugs effectively. This guide provides clear instructions to ensure you complete each section accurately and efficiently.

Follow the steps to fill out the form online

1. Click ‘Get Form’ button to obtain the Keystone Vip Choice Prior Authorization Form and open it in your preferred editor.
2. Begin by entering the enrollee’s information. This includes the enrollee’s name, date of birth, address, phone number, and member ID number.
3. If the requestor is not the enrollee or prescriber, fill out the requestor’s information, including their name, relationship to the enrollee, address, and phone number.
4. In the section for the requested prescription drug, specify the name of the drug, including strength and quantity requested per month.
5. Select the appropriate type of coverage determination request by checking the applicable box. Be sure to understand which request applies to your situation.
6. If any supporting documents or information are required, attach them to the form. This is particularly important for formulary or tiering exceptions.
7. For expedited decisions, check the relevant box if you believe that waiting 72 hours could harm the enrollee’s health, and ensure to attach supporting documentation from the prescriber if applicable.
8. Sign and date the form to confirm that the information provided is accurate and complete.
9. Finally, save changes to your form, and consider downloading, printing, or sharing the completed document as necessary.

Complete your Keystone Vip Choice Prior Authorization Form online today.