Get Pharmacy Prior Authorization Form - Pharmacy - Keystone First

This guide presents a step-by-step approach to completing the Pharmacy Prior Authorization Form for ®, ®, or ® with Keystone First online. Following these instructions can help ensure smooth processing of your authorization requests.

Follow the steps to complete the form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information, including their date of birth, full name, and patient ID number. Ensure accuracy to avoid processing delays.
3. Provide details about the prescribing physician, including their name, phone number, DEA number, fax number, and address. This information is essential for validating the prescription.
4. Select the drug being requested, choosing from ®, ®, or ®. Indicate the specific dosage by selecting the appropriate options from the listed strengths.
5. Specify the anticipated length of therapy in days or months, but remember to adhere to the maximum allowable periods of therapy as stated.
6. Enter the diagnosis related to the treatment request. This should be concise yet descriptive enough for review.
7. Indicate if this is an initial request or a renewal request. Each has specific criteria that must be met for approval.
8. For initial requests, ensure that all applicable criteria are checked based on the patient's situation. Any unchecked boxes will need additional explanations on subsequent pages.
9. For renewal requests, document the necessary information about the patient’s treatment history, including medication compliance and participation in counseling.
10. Provide additional rationale or information as needed for review, especially if previous criteria were not met.
11. Select the delivery option for the form. Options include the member’s home, the physician’s office, or the member’s preferred pharmacy. Confirm the pharmacy information as necessary.
12. Have the physician sign the form and date it. This is crucial for the authorization process.
13. Once completed, save the changes, and download, print, or share the completed form as required.

Complete your Pharmacy Prior Authorization Form online now for a swift processing experience.