Prior Authorization Request. Español | 中文 | Việt Nam | 한국어 | təˈɡäləɡ | Русский | Kreyòl Fwansè | العربية | Polski | Français | Italiano | Հայերէն | فارسی | 日本語 | ភាសាខ្មែរ. It’s an online prior authorization request that gets instantly submitted to PerformRx. PerformRx 200 Stevens Drive Philadelphia, PA 19113 Please fax this form to: 855-829-2872 PerformRx Provider Services: Phone: 855-251-0966 . Prior Authorization Request Confidential Information June 2020 PH-ANR-25/Rev070120. 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. Submitted to: Phone: Fax: Date: S. LOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM . PerformRx Remains Fully Operational Rest assured – we will continue to serve you and your members without disruption during this difficult time. Step 1 – First fill out the patient’s full name, date of birth and ID number. 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. Let PerformRx be your PBM resource. You will also need to write your justification for making this request. An incomplete form may be returned. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠. 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. 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. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057. Page 1 of 2 Version 1.0 - 2018-12 . An ineffective prior authorization program can prove costly on not only the formulary side, but on the administrative side as well. Recent updates. 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. 1-855-446-7905, or to speak to a representative call. CONFIDENTIAL INFORMATION. © 2020 Electronic Forms LLC. Philadelphia, PA 19113. Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / / Recipient’s Full Name . CONFIDENTIAL INFORMATION. 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. PerformPA ® is an easy-to-use online pharmacy prior authorization (PA) tool designed to simplify and streamline the prior authorization process. SM. 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. PerformSpecialty® is everything you want from a specialty pharmacy, done better. California Code of Regulations, Section 1300.67.241, requires prescribers to use pharmacy prior authorization Form No. Prior (Rx) Authorization Forms Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. Prior Authorization Request Form For assistance please call (855) 707-5818: Drug Information. 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. SM. Information contained in this form is Protected Health Information under HIPAA. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. 1-888-981-5202, or to speak to a representative call. The form should be submitted by following the steps on the form. I — S PerformPA® was designed to be easy to teach and easy to use by anyone. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. 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. Our tool was created by clinical experts for the clinical community to simplify the PA process. Attach member specific documents such as labs, chart notes, consults etc. We want to make prescribers’ jobs easier. prestige health choice, performrx, perform rx, provider, pharmacy, prior authorization, prior auth, form, forms, miscellaneous, misc, Created Date: 5/15/2015 … It’s an online prior authorization request that gets instantly submitted to PerformRx. All rights reserved. The clinical community to simplify the PA process Birth ( MM/DD/YYYY ) / recipient... Authorizations, meaning we know the service better than anyone a specialty pharmacy ; we are an organization dedicated managing... ( form effective 1/1/20 ) Fax to PerformRx under HIPAA the clinical community simplify... S why we created performpa®: to do pharmacy prior authorizations, meaning we know the service than... Our agents are not licensed attorneys and can not address legal questions, we! 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