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Keystone first prior authorization

Keystone first prior auth forms 2026

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The document is a Universal Pharmacy Oral Prior Authorization Form used to request approval for medication prescriptions. It includes sections for patient and physician information, medication details, diagnosis, previous therapies, and additional rationale. The form must be signed by the physician and returned to PerformRx via mail or fax.

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Click ‘Get Form’ to open the Keystone First Prior Authorization Form in the editor.
Begin by entering the Patient Name and Date of Birth (DOB) in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the Patient ID Number, followed by the Physician's Name and Phone number. This section helps establish communication between healthcare providers.
Complete the Specialty and Fax fields, along with the Physician's License Number and Address. This information is necessary for verification purposes.
In the Medication Name and Strength Requested section, specify the medication along with its dosage. Include clear directions for use.
Indicate the Anticipated Length of Therapy by selecting an option: Days, 3 Months, or 6 Months.
Provide a detailed Diagnosis and list any Preferred Medications that have been tried previously, including their strength, frequency, and duration.
Finally, add any Rationale or additional information relevant to this prior authorization request before signing and dating the form.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the phone number for Keystone First prior authorization?

If you have questions about this tool or a service or to request a prior authorization, call 1-800-521-6622.

Is Keystone first the same as Blue Cross?

In 2012, backed by parent companies Independence Blue Cross and Blue Cross Blue Shield of Michigan, Keystone Mercy became Keystone First. Today, Keystone First serves more than 300,000 Medical Assistance recipients in the five-county Greater Philadelphia area.

How good is Keystone First insurance?

Keystone First earned its 4.0 out of 5 rating based on strong results from the Healthcare Effectiveness Data and Information Set (HEDIS), a tool that measures performance on important dimensions of care and service, as well as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which measures

Who funds Keystone First?

Keystone First VIP Choice contracts with the Centers for Medicare Medicaid Services (CMS). Keystone First VIP Choice is funded by the federal government to manage Medicare benefits for our members.

What kind of insurance is Keystone First?

Keystone First is a Medical Assistance (Medicaid) managed care health plan that was founded by the Sisters of Mercy in 1982 to help people get care, stay well, and build healthy communities. Today, we remain committed to that mission.

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Is Keystone First part of Blue Cross Blue Shield?

Keystone First was founded by the Sisters of Mercy in 1982 as the Mercy Health Plan. The company is a subsidiary of Independence Blue Cross.

Is Keystone first Pennsylvania Medicaid?

Keystone First is a medical assistance (Medicaid and Medicare) managed care health plan based in southeastern Pennsylvania.

Keystone first prior auth forms 2026

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