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Prior Authorization

For Keystone 65 Complete

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Certain covered drugs that have been approved by the FDA for specific medical conditions require prior authorization. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Formulary Search

Search our drug formulary by drug name or drug class.

When a member presents a prescription at a participating network pharmacy, the pharmacy is informed, using the claims processing point-of-service system. If the requested drug is either non-formulary or requires prior authorization, the pharmacy then notifies the member, contacts the prescribing physician, and/or contacts PerformRx to determine the appropriate course of action.

In order to obtain a prior authorization for a medication, these steps should be followed:

1. The prescribing physician must submit an “explanation of medical necessity.”
2. A clinical pharmacist at PerformRx, our Pharmacy Benefits Manager, will review the information submitted by your doctor.
3. If the reviewing pharmacist does not agree that there is adequate clinical justification to approve the medication, the request is forwarded to the Plan’s Medical Director for final review and determination.
4. If the request is denied, the prescribing provider is notified of the denial by fax. A mailed denial letter is sent to the patient.
5. Following a denial, the member has several additional appeal and grievance options.

Providers who would like to submit a prior authorization request, may either contact our provider help desk at 1-888-684-5502, or use our prior authorization request form. Please answer all questions on the form and fax to the phone number listed on the form. A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format. The forms for the current prior authorization medications are:

• Aranesp® Request Form
• Botox® or Myobloc® Request Form
• Chemotherapy Drug Request Form
• Enbrel® or Humira® Self Injectable AS, PsA, Psoriasis Biologics Request Form (For Treating Arthritis)
• Enbrel® or Humira® Self Injectable RA Biologics Request Form (For Treating Arthritis)
• Forteo®/Boniva® Injection Request Form
• Fuzeon® Lab Tracking Form
• Fuzeon® Medication History Form
• Fuzeon® Prior Authorization Request Form
• Growth Hormone Request Form
• Home Infusion Request Form
• Lupron®/Zoladex® Request Form
• Office Administered Injectable Drug Request Form
• Pegasys Peg Intron Interferon Request Form (for Hepatitis C treatment)
• Procrit Request Form
• Remicade® Request Form
• Risperdal-Consta® Request Form
• Self-Administered Injectable and Specialty Drugs Request Form
• Serostim® Request Form
• White Blood Cell Stimulators (Leukine®, Neupogen®, Neulasta®) Request Form
• Xolair® Prior Authorization Request Form

General Pharmacy Prior Authorization Form

Members wishing to check on the status of a prior authorization request submitted by their doctor should contact our Customer Service department.

Members call toll free 1-888-457-3108 (TTY/TDD#: 1-888-857-4816) 8 a.m. to 8 p.m., seven days a week.

Providers wishing to check on the status of a prior authorization request they have submitted should contact our provider help desk.

Providers call toll free 1-800-684-5502.