Our staff uses PerformPA to process our pharmacy prior authorizations, meaning we know the service better than anyone. Please be aware that our agents are not licensed attorneys and cannot address legal questions. Free PerformRX Prior (Rx) Authorization Form - PDF . For assistance, please contact Utilization Management (UM) at . Submit the completed form: By fax: Attention Pharmacy at 1-855-811-9326 By mail: PerformRx, Attention: 4. th. We work hand-in-hand with our own full-service specialty pharmacy to make it easier for your patients to get the specialty mediations and treatments they need. SM. Orfadin® Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Orfadin® Prior Authorization Form Keywords: Orfadin® Prior Authorization Form. Español | 中文 | Việt Nam | 한국어 | təˈɡäləɡ | Русский | Kreyòl Fwansè | العربية | Polski | Français | Italiano | Հայերէն | فارسی | 日本語 | ភាសាខ្មែរ. meriHealth Caritas . Drug Search Enter values for one or more of the below drug search fields. It’s an online prior authorization request that gets instantly submitted to PerformRx. For more information on PerformPA, contact us by completing the form below: For years, PerformRx’s clinicians used a variety of pharmacy prior authorization platforms, but there were always problems. SM. Processing pharmacy prior authorizations (PA) efficiently is a major hurdle for pharmacy benefit managers (PBMs). PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION: Patient name: Patient ID#: DOB: Street address: Apt. 1-855-446-7905, or to speak to a representative call. © 2020 Electronic Forms LLC. Prior Authorization Request Form: Drug Information. Specialty medicines. 1-888-981-5202, or to speak to a representative call. Built by a team of clinicians at PerformRx, PerformPA walks users through the prior authorization process step-by-step with a simple tab-based guide. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057. Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name . Please contact Coastal Care Services at . KF_19721461-7. Attach member specific documents such as labs, chart notes, consults etc. The Prior Authorization Request (PDF) form must be completed. Submit an Online Prior Authorization Form . Information contained in this form is Protected Health Information under HIPAA. S. ECTION . Philadelphia, PA 19113. If you’re having trouble, download the printable Prior Authorization form (PDF). I — S For medications not normally covered under a patient’s medical insurance plan, a PerformRX Prior Authorization Form will need to be filled out by a pharmacist in order to request coverage. 200 Stevens Drive. The form should be submitted by following the steps on the form. An incomplete form may be returned. The updated PA form is attached below. Perform PA is also fully HIPAA compliant. chart notes or lab data, to support the prior authorization or step-therapy exception request. Many offered confusing interfaces that were hard to teach to new employees, while others did not offer all of the necessary information in one location, and some were never updated to meet the latest regulations. Keystone First. Print summary page for easy referencing. It's a prior authorization request form you complete online. Or FAX to . 1-855-371-8074. Step 4 – You will then need to list any preferred medications that have been tried to treat the patient’s relevant diagnosis, listing the strength, frequency, and duration for each. Reduce review time. We keep it up-to-date for our business, so it’s sure to be right for yours. 61-211 for non-Medicare health plans. We want to make prescribers’ jobs easier. You will also need to write your justification for making this request. Step 1 – First fill out the patient’s full name, date of birth and ID number. California Code of Regulations, Section 1300.67.241, requires prescribers to use pharmacy prior authorization Form No. Attach member-specific documents such as labs, chart notes, consults and more. 1-855-481-0505. regarding authorization of durable medical equipment (DME) and home health services. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, miscellaneous, misc, Created Date: 5/15/2015 … prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, orfadin, Created Date: 7/18/2014 3:49:58 PM CONFIDENTIAL INFORMATION. PerformPA is fully compliant with all state and federal laws and provides multiple features designed to simplify, document and improve the prior authorization process. 1-800-588-6767. SM. All specialty medicines, such as those for complex diseases, require prior authorization. 200 Stevens DrivePhiladelphia, PA 19113info@performrx.com1-866-533-5492. 1-866-610-2774. Injectable Requests-Please call. CONFIDENTIAL INFORMATION. 1-215-937-5018, or to speak to a representative call . **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. Below you will find the different available forms for each associated health plan, as well as the fax and phone numbers that you will need to use. What are the benefits? 1-800-588-6767. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠. All rights reserved. Our tool was created by clinical experts for the clinical community to simplify the PA process. at . Drug Search Enter values for one or more of the below drug search fields. Our easy-to-use functionality goes beyond processing pharmacy prior authorization. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Step 5 – Finally, at the bottom of the form, you must provide your written signature and the date. PerformPA includes every part of the PA process so your employees never miss a step. Online: Online prior authorization request form Phone: Call 1-888-602-3741 Fax: To PerformRx ℠ at 1-855-811-9332. SM. Floor Prior Auth Dept 200 Stevens Drive, Philadelphia, PA 19113. If you’re having trouble, download the printable prior authorization form (PDF). PerformRx 200 Stevens Drive Philadelphia, PA 19113 Please fax this form to: 855-829-2872 PerformRx Provider Services: Phone: 855-251-0966 . SM. What is it? Taking care of patients is what health care providers do best. PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. Create a high quality document online now! PerformRx’s staff uses PerformPA daily and updates it to meet the latest regulations. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 1-888-674-8720. 1-855-851-4058, or to speak to a representative call . Since we need to use it, we regularly update it to meet the latest Medicare and Medicaid regulations and commercial requirements, and those updates are immediately available to all of our users. Prior Authorization Request Form For assistance please call (855) 707-5818: Drug Information. PerformRx Remains Fully Operational Rest assured – we will continue to serve you and your members without disruption during this difficult time. Health Details: For medications not normally covered under a patient’s medical insurance plan, a PerformRX Prior Authorization Form will need to be filled out by a pharmacist in order to request coverage. 1-866-610-2774. PerformPA® was designed to be easy to teach and easy to use by anyone. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. PerformPA Your Pharmacy Prior Authorization Solution. With PerformPA you have: PerformPA® is not just a program we sell—it’s a program we use every day. Recent updates. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. To submit requests, please fax completed form to . Submitted to: Phone: Fax: Date: S. LOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM . Fill it out and your PA requests are instantly submitted to PerformRx. Utilizing a tab-based interface, the tool breaks the PA process down into a logical series of steps and helps to walk the user through the process. Step 3 – Below that, you will need to provide the name and strength of the medication that you are requesting coverage for, as well as the directions for use, the anticipated length of therapy, and the related diagnosis. We provide useful resources such as drug information updates and web prior authorization submission forms all in one convenient place. 1-855-236-9285. CONFIDENTIAL INFORMATION. Effective May 26, 2020, reimbursement for administration of designated drugs at a hospital-based facility is available only if specific criteria are met. at . Prior (Rx) Authorization Forms Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. Submit online prior authorization Having trouble using the online form? Pharmacy Miscellaneous Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Pharmacy Miscellaneous Prior Authorization Form Keywords: Pharmacy Miscellaneous Prior Authorization Form. What is it? PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. With PerformPA, you know we have your interests in mind. Using our online web submission form providers will be able to: Electronically submit all relevant member information. That’s because we are more than specialty pharmacy; we are an organization dedicated to managing the complete care of our patients. Prior authorizations for injectable medications. A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. An ineffective prior authorization program can prove costly on not only the formulary side, but on the administrative side as well. Our pandemic task force is monitoring the developments around COVID-19 to identify, develop, and implement responses that promote the health of your members, ensure the safety of our associates, and maintain the continuity of our business. Made Fillable by eForms. It’s an online prior authorization request that gets instantly submitted to PerformRx. Both physicians and pharmacists are continually asked to fit more work into the same 24-hour schedule, and that’s where PerformRx comes in. 2019 Searchable Behavioral Health Services that Require Prior Authorization for Hoosier Healthwise and HIP; Prior Authorization Form Archives For pharmacy prior authorization forms, please visit our pharmacy forms page. PIDw sc . PerformPA ® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. Bluelink TPA Synagis Forms: Printed Form / Fillable Form. Step 2 – Next, fill in your full name (as the physician), your specialty, your phone and fax numbers, your NPI number, and your complete address. at . Page 1 of 2 Version 1.0 - 2018-12 . Subsequent to California Senate Bill (SB) 282, updates to Form 61-211 were made in December, 2017. Rationale and/or additional information, which may be relevant to the review of this prior authorization request: Prescriber Signature Date Please fax this form to: PerformRx Located at 200 Stevens Drive Philadelphia, PA 19113 Standard Request: 1-855-811-9324 Urgent Request: 1-855-811-9325 PerformRx Provider Services: Phone: 1-855-491-0633. Prior Authorization Request Form For assistance please call (866) 935-6681: Drug Information. Opioid-related prior authorization request forms: Long-acting opioid prior authorization form (PDF) Short-acting opioid prior authorization form (PDF) Opioid dependence treatments (oral) prior authorization form (PDF) Opioid treatment information. Prior Authorization Request. 1-215-937-5018. PerformRx. Our support agents are standing by to assist you. Built by a team of clinicians at PerformRx, PerformPA walks users through the prior authorization process step-by-step with a simple tab-based guide. 1-888-981-5202, or to speak to a representative call. #: City/state/zip: PRESCRIBER … , Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan to. To submit requests, please contact Utilization Management ( UM ) at Search Enter values for one or more the. ( UM ) at Section 1300.67.241, requires prescribers to use by anyone request ( )! 7/21/20 ) Fax to PerformRx ℠ at 1-855-811-9332: Printed form / Fillable form lab data, to support prior... 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