1-215-937-5018. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. 61-211 are located at these websites in convenient PDF format: (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. 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. Attach member specific documents such as labs, chart notes, consults etc. Recent updates. PerformPA® was designed to be easy to teach and easy to use by anyone. Print summary page for easy referencing. An ineffective prior authorization program can prove costly on not only the formulary side, but on the administrative side as well. 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. 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. PerformPA includes every part of the PA process so your employees never miss a step. 1-800-588-6767. Prior (Rx) Authorization Forms Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. 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. It’s an online prior authorization request that gets instantly submitted to PerformRx. With PerformPA, you know we have your interests in mind. S. ECTION . Information contained in this form is Protected Health Information under HIPAA. Bluelink TPA Synagis Forms: Printed Form / Fillable Form. Prior Authorization Request Confidential Information June 2020 PH-ANR-25/Rev070120. The PerformRx online prior authorization form is a prior authorization request form that providers complete online. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. What is it? 1-888-981-5202, or to speak to a representative call. Made Fillable by eForms. Our easy-to-use functionality goes beyond processing pharmacy prior authorization. If you’re having trouble, download the printable Prior Authorization form (PDF). Injectable Requests-Please call. Perform PA is also fully HIPAA compliant. PerformRx’s staff uses PerformPA daily and updates it to meet the latest regulations. 1-866-610-2774. What are the benefits? Get instant approvals for specific drugs. #: City/state/zip: PRESCRIBER … With PerformPA you have: PerformPA® is not just a program we sell—it’s a program we use every day. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total pages: Office contact/phone: LTC facility contact/phone: PATIENT INFORMATION: Patient name: Patient ID#: DOB: Street address: Apt #: City/state/zip: PRESCRIBER … We keep it up-to-date for our business, so it’s sure to be right for yours. Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name . PerformPA Your Pharmacy Prior Authorization Solution. What is it? It’s an online prior authorization request that gets instantly submitted to PerformRx. You will also need to write your justification for making this request. 1-855-446-7905, or to speak to a representative call. at . 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. 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. The form should be submitted by following the steps on the form. Using our online web submission form providers will be able to: Electronically submit all relevant member information. SM. To submit requests, please fax completed form to . If you’re having trouble, download the printable prior authorization form (PDF). That’s because we are more than specialty pharmacy; we are an organization dedicated to managing the complete care of our patients. Pharmacy Miscellaneous Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Pharmacy Miscellaneous Prior Authorization Form Keywords: Pharmacy Miscellaneous Prior Authorization Form. Submit the completed form: By fax: Attention Pharmacy at 1-855-811-9326 By mail: PerformRx, Attention: 4. th. 1-855-851-4058, or to speak to a representative call . Prior Authorization Request Form For assistance please call (866) 935-6681: Drug Information. Both physicians and pharmacists are continually asked to fit more work into the same 24-hour schedule, and that’s where PerformRx comes in. 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. Please contact Coastal Care Services at . SM. © 2020 Electronic Forms LLC. Step 1 – First fill out the patient’s full name, date of birth and ID number. SM. CONFIDENTIAL INFORMATION. Pharmacy Prior Authorization Form Save time and reduce paperwork by using the PerformRx℠ online prior authorization form. All rights reserved. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. SM. We want to make prescribers’ jobs easier. 200 Stevens Drive. Keystone First. CONFIDENTIAL INFORMATION. Submit an Online Prior Authorization Form . 61-211 for non-Medicare health plans. Drug Search Enter values for one or more of the below drug search fields. PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. Our tool was created by clinical experts for the clinical community to simplify the PA process. Prior authorizations for injectable medications. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, orfadin, Created Date: 7/18/2014 3:49:58 PM 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. What are the benefits? PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Processing pharmacy prior authorizations (PA) efficiently is a major hurdle for pharmacy benefit managers (PBMs). It's a prior authorization request form you complete online. Philadelphia, PA 19113. An incomplete form may be returned. at . PerformPA is fully compliant with all state and federal laws and provides multiple features designed to simplify, document and improve the prior authorization process. Let PerformRx be your PBM resource. 1-888-674-8720. 1-855-481-0505. regarding authorization of durable medical equipment (DME) and home health services. The updated PA form is attached below. I — S 1-866-610-2774. 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. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠. Prior Authorization Request Form: Drug Information. Drug Search Enter values for one or more of the below drug search fields. Attach member-specific documents such as labs, chart notes, consults and more. For assistance, please contact Utilization Management (UM) at . 1-800-588-6767. Our staff uses PerformPA to process our pharmacy prior authorizations, meaning we know the service better than anyone. Drug Search Enter values for one or more of the below drug search fields. Create a high quality document online now! PerformPA® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. 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. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Or FAX to . PerformSpecialty® is everything you want from a specialty pharmacy, done better. 1-855-236-9285. Reduce review time. 1-855-371-8074. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax 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. PerformRx Remains Fully Operational Rest assured – we will continue to serve you and your members without disruption during this difficult time. That’s why we created PerformPA®: to do pharmacy prior authorization (PA) the right way. at . 1-215-937-5018, or to speak to a representative call . 2020 Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP - NEW! Page 1 of 2 Version 1.0 - 2018-12 . chart notes or lab data, to support the prior authorization or step-therapy exception request. Español | 中文 | Việt Nam | 한국어 | təˈɡäləɡ | Русский | Kreyòl Fwansè | العربية | Polski | Français | Italiano | Հայերէն | فارسی | 日本語 | ភាសាខ្មែរ. Submitted to: Phone: Fax: Date: S. LOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM . 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. Our support agents are standing by to assist you. 200 Stevens DrivePhiladelphia, PA 19113info@performrx.com1-866-533-5492. KF_19721461-7. Prior Authorization SYNAGIS® – All Florida Regions Combined Coverage Period: July 1st through April 30th Maximum number of doses: (No authorizations for May and June) Note: Form must be completed in full. CONFIDENTIAL INFORMATION. Submit online prior authorization Having trouble using the online form? Online: Online prior authorization request form Phone: Call 1-888-602-3741 Fax: To PerformRx ℠ at 1-855-811-9332. PerformPA ® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. 1-888-208-1020. Attach any additional documentation that is important for the review, e.g. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, miscellaneous, misc, Created Date: 5/15/2015 … 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. 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. **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057. Prior Authorization Request Form For assistance please call (855) 707-5818: Drug Information. All specialty medicines, such as those for complex diseases, require prior authorization. Designed by pharmacists who understand the PA process and used by our prior authorization team daily, PerformPA includes the entire PA process in one web-based location. PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. This form is attached below. California Code of Regulations, Section 1300.67.241, requires prescribers to use pharmacy prior authorization Form No. A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. PerformRx 200 Stevens Drive Philadelphia, PA 19113 Please fax this form to: 855-829-2872 PerformRx Provider Services: Phone: 855-251-0966 . 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. Please be aware that our agents are not licensed attorneys and cannot address legal questions. We provide useful resources such as drug information updates and web prior authorization submission forms all in one convenient place. 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. PerformRX Prior (Rx) Authorization Form. Specialty medicines. meriHealth Caritas . at . **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. PerformRx. Step 5 – Finally, at the bottom of the form, you must provide your written signature and the date. Free PerformRX Prior (Rx) Authorization Form - PDF . PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. The Prior Authorization Request (PDF) form must be completed. Effective May 26, 2020, reimbursement for administration of designated drugs at a hospital-based facility is available only if specific criteria are met. Subsequent to California Senate Bill (SB) 282, updates to Form 61-211 were made in December, 2017. 1-888-981-5202, or to speak to a representative call. Orfadin® Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Orfadin® Prior Authorization Form Keywords: Orfadin® Prior Authorization Form. Taking care of patients is what health care providers do best. SM. PIDw sc . Floor Prior Auth Dept 200 Stevens Drive, Philadelphia, PA 19113. Fill it out and your PA requests are instantly submitted to PerformRx. Prior Authorization Request. 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. at . 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