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Pharmacy Prior Authorization

Opioid treatment resources

Keystone First continues to carefully review and update our requirements for opioid prescriptions. Our collaborative goal with you is to ensure that our members are receiving the correct treatment for their pain and that opioid utilization is managed and monitored appropriately. We will continue to provide you with the most up-to-date information and resources to attain that goal.

Opioid-related prior authorization request forms:

Opioid treatment information

Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or which have been indicated as requiring prior authorization.

For more information on the pharmacy prior authorization process, call the Pharmacy Services department at 1-800-588-6767.

Important payment notice

Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Effective January 1, 2018, any claim submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.

To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.

How to submit a request for pharmacy prior authorization

Online

Save time by submitting all your pharmacy prior authorization requests online. Get started at our online prior authorization request form or learn more in our tutorial.

By phone

Call the Pharmacy Services department at 1-800-588-6767. Outside of normal business hours, call Member Services at 1-800-521-6860.

By fax

Please see available prior authorization request forms below.

Prior authorization criteria

Many medicines have specific requirements and conditions that must be met to receive prior authorization. Save time by viewing a list of medications and their prior authorization criteria (PDF) before submitting your request.

Drug- and drug class-specific prior authorization request forms

Specialty and injectable request forms

Specialty drugs include unusually high-cost oral, inhaled, injectable, and infused pharmaceuticals prescribed for a relatively narrow spectrum of diseases and conditions.

To initiate a request for specialty or injectable drugs administered in a physician’s office, or for injectable medications dispensed through network specialty or retail pharmacies for patient self-administration, use one of the drug- or class-specific prior authorization request forms below.

The form must be completed in its entirety and faxed to the Specialty Drug Management Program at 1-215-937-5018. Failure to submit all requested information could result in denial of coverage or a delay of approval as the result of insufficient information.

General prior authorization request form