PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. 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. © 2020 Electronic Forms LLC. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠. Perform PA is also fully HIPAA compliant. This form is attached below. 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. 1-855-236-9285. 1-215-937-5018, or to speak to a representative call . Submit online prior authorization Having trouble using the online form? 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. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057. Prior (Rx) Authorization Forms Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. 61-211 for non-Medicare health plans. **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. All specialty medicines, such as those for complex diseases, require prior authorization. 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. Our support agents are standing by to assist you. Prior Authorization Request Form For assistance please call (866) 935-6681: Drug Information. PIDw sc . at . That’s why we created PerformPA®: to do pharmacy prior authorization (PA) the right way. Prior Authorization Request Confidential Information June 2020 PH-ANR-25/Rev070120. With PerformPA, you know we have your interests in mind. SM. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, orfadin, Created Date: 7/18/2014 3:49:58 PM Online: Online prior authorization request form Phone: Call 1-888-602-3741 Fax: To PerformRx ℠ at 1-855-811-9332. We keep it up-to-date for our business, so it’s sure to be right for yours. 1-888-981-5202, or to speak to a representative call. Keystone First. chart notes or lab data, to support the prior authorization or step-therapy exception 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. 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 … If you’re having trouble, download the printable Prior Authorization form (PDF). SM. PerformPA ® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. 61-211 are located at these websites in convenient PDF format: 1-800-588-6767. Our easy-to-use functionality goes beyond processing pharmacy prior authorization. Let PerformRx be your PBM resource. Page 1 of 2 Version 1.0 - 2018-12 . S. ECTION . All rights reserved. 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. Processing pharmacy prior authorizations (PA) efficiently is a major hurdle for pharmacy benefit managers (PBMs). 200 Stevens DrivePhiladelphia, PA 19113info@performrx.com1-866-533-5492. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, miscellaneous, misc, Created Date: 5/15/2015 … CONFIDENTIAL INFORMATION. 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. Using our online web submission form providers will be able to: Electronically submit all relevant member information. 1-866-610-2774. 1-855-851-4058, or to speak to a representative call . What is it? Bluelink TPA Synagis Forms: Printed Form / Fillable Form. 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’s staff uses PerformPA daily and updates it to meet the latest regulations. SM. CONFIDENTIAL INFORMATION. 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. The updated PA form is attached below. PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. Floor Prior Auth Dept 200 Stevens Drive, Philadelphia, PA 19113. Information contained in this form is Protected Health Information under HIPAA. Drug Search Enter values for one or more of the below drug search fields. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Print summary page for easy referencing. 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. We provide useful resources such as drug information updates and web prior authorization submission forms all in one convenient place. 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. What is it? 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. I — S 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. 1-855-371-8074. Effective May 26, 2020, reimbursement for administration of designated drugs at a hospital-based facility is available only if specific criteria are met. Step 1 – First fill out the patient’s full name, date of birth and ID number. Attach member-specific documents such as labs, chart notes, consults and more. Recent updates. You will also need to write your justification for making this request. 1-855-446-7905, or to speak to a representative call. CONFIDENTIAL INFORMATION. Free PerformRX Prior (Rx) Authorization Form - PDF . SM. Prior authorizations for injectable medications. PerformRX Prior (Rx) Authorization Form. 1-215-937-5018. meriHealth Caritas . 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. PerformPA Your Pharmacy Prior Authorization Solution. Step 5 – Finally, at the bottom of the form, you must provide your written signature and the date. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. Please contact Coastal Care Services at . #: City/state/zip: PRESCRIBER … 1-855-481-0505. regarding authorization of durable medical equipment (DME) and home health services. It's a prior authorization request form you complete online. at . Español | 中文 | Việt Nam | 한국어 | təˈɡäləɡ | Русский | Kreyòl Fwansè | العربية | Polski | Français | Italiano | Հայերէն | فارسی | 日本語 | ភាសាខ្មែរ. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. We want to make prescribers’ jobs easier. Subsequent to California Senate Bill (SB) 282, updates to Form 61-211 were made in December, 2017. PerformSpecialty® is everything you want from a specialty pharmacy, done better. The PerformRx online prior authorization form is a prior authorization request form that providers complete online. Please be aware that our agents are not licensed attorneys and cannot address legal questions. Drug Search Enter values for one or more of the below drug search fields. 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