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Prior Authorization

For Keystone 65 Complete

• Overview |
• Formulary |
• Generic and Brand-Name Drugs |
• Prior Authorization |
• Exceptions and Appeals |
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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 Request Form
• Enbrel Self Injectable Biological Request Form (For Treating Arthritis)
• Forteo®/Boniva® Coverage Determination Form
• Fuzeon Lab Tracking Form
• Fuzeon Medication History Form
• Fuzeon Prior Authorization Request Form
• Patient Self-Administered Growth Hormone Request Form
• Home Infusion Therapies Request Form
• Humira Self Injectable Biological Request Form (For Treating Arthritis)
• Patient Self-Administered Injectable and Specialty Drugs Request Form
• Kineret Self Injectable Biological Request Form (For Treating Arthritis)
• Leukine Request Form
• Myobloc Request Form
• Neupogen Request Form
• Self Injectable Non Pegylated Interferons Request Form (for Hepatitis C treatment)
• Self Injectable Pegasys Interferons Request Form (for Hepatitis C treatment)
• Self Injectable Peg-Intron Interferons Request Form (for Hepatitis C treatment)
• Procrit Request Form
• Self Injectable Ribavirin Interferons Request Form (for Hepatitis C treatment)
• Risperdal-Consta Request Form
• Serostim Prior Authorization 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 member services 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.