Keystone First (Rx) Prior Authorization Form

Updated December 31, 2021

A Keystone First Prior Authorization Form allows physicians to secure coverage for a non-preferred medication on behalf of their patients.

  • Fax: 1 (215) 937-5018
  • Prior Authorization Retro Fax: 1 (215) 937-737
  • DME Fax: 1 (215) 937-5383
  • OB Request Fax: 1 (844) 688-2973
  • Phone: 1 (800) 588-6767

How to Write

Step 1 In the first section of the prior authorization form, you will be asked to provide the following information regarding your facility:

  • Facility name
  • NPI number
  • Tax ID #
  • Complete address
  • Phone #
  • Fax #

Step 2 – Next, you will need to enter the following provider information (this is you):

  • Provider’s name
  • Keystone First provider ID
  • NPI #
  • Tax ID #
  • Complete address
  • Phone and fax #
  • Preparer’s name
  • Preparer’s phone and fax #
  • Date faxed
  • Number of pages

Step 3 – In Patient information, you are required to enter the patient’s name, their Keystone First ID number, their date of birth, their eligibility date, and any third-party liability information.

Step 4 – Next, check the appropriate box to indicate the type of request being sent.

Step 5 – In the bottom two windows, submit the following data:

  • Date and type of requested service
  • Treating physician name and NPI #
  • Pending authorization #
  • Dx/CPT/HCPC codes
  • Referring physician name, NPI #, phone #, and fax #