#: City/state/zip: PRESCRIBER … PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. Prior Authorization Request Form For assistance please call (866) 935-6681: Drug Information. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 1-800-588-6767. If you’re having trouble, download the printable Prior Authorization form (PDF). PerformRx. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠. Prior Authorization Request. PerformPA includes every part of the PA process so your employees never miss a step. 1-215-937-5018, or to speak to a representative call . Prior Authorization Request Form: Drug Information. SM. PerformPA Your Pharmacy Prior Authorization Solution. Injectable Requests-Please call. 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 … PerformPA is fully compliant with all state and federal laws and provides multiple features designed to simplify, document and improve the prior authorization process. Made Fillable by eForms. Drug Search Enter values for one or more of the below drug search fields. 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. The form should be submitted by following the steps on the form. 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. PerformRx Remains Fully Operational Rest assured – we will continue to serve you and your members without disruption during this difficult time. at . Taking care of patients is what health care providers do best. SM. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057. Submit online prior authorization Having trouble using the online form? Orfadin® Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Orfadin® Prior Authorization Form Keywords: Orfadin® Prior Authorization Form. 1-866-610-2774. 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. We provide useful resources such as drug information updates and web prior authorization submission forms all in one convenient place. You will also need to write your justification for making this request. 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. Our tool was created by clinical experts for the clinical community to simplify the PA process. Reduce review time. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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. SM. **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. PerformRx 200 Stevens Drive Philadelphia, PA 19113 Please fax this form to: 855-829-2872 PerformRx Provider Services: Phone: 855-251-0966 . Or FAX to . What is it? Prior (Rx) Authorization Forms Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. KF_19721461-7. **Prior authorization requests submitted on other forms will not be accepted** Fillable New Prior Authorization Forms Prior Authorization Form No. Online: Online prior authorization request form Phone: Call 1-888-602-3741 Fax: To PerformRx ℠ at 1-855-811-9332. The PerformRx online prior authorization form is a prior authorization request form that providers complete online. Step 5 – Finally, at the bottom of the form, you must provide your written signature and the date. Both physicians and pharmacists are continually asked to fit more work into the same 24-hour schedule, and that’s where PerformRx comes in. It’s an online prior authorization request that gets instantly submitted to PerformRx. 200 Stevens Drive. Keystone First. PerformPA ® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. Prior Authorization Request Confidential Information June 2020 PH-ANR-25/Rev070120. Pharmacy Miscellaneous Prior Authorization Form - Providers - Prestige Health Choice Author: PerformRx Subject: Pharmacy Miscellaneous Prior Authorization Form Keywords: Pharmacy Miscellaneous Prior Authorization Form. It’s an online prior authorization request that gets instantly submitted to PerformRx. It's a prior authorization request form you complete online. A Philadelphia, PA 19113 please Fax this form to: Phone: 855-251-0966: Electronically submit all member! 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