Pharmacy Prior Authorization

Online pharmacy prior authorization

The PerformRx online prior authorization form is a prior authorization request form that providers complete online. Once you submit the form, your prior authorization requests are instantly submitted to PerformRx℠.

Submit online prior authorization

Having trouble using the online form? Download the printable prior authorization form (PDF).

Benefits of the online prior authorization form

Save time by: 

  • Reducing prior authorization review time
  • Giving instant approvals for specific drugs
  • Attaching member-specific documents such as labs, chart notes, consults and more (formats: pdf, doc, xls, ppt, txt)
  • Saving unique provider information to speed up future submissions
  • Printing a summary page for easy reference

Getting started

Start using this form today and streamline your prior authorization requests.

  • Take PerformRx's online prior authorization tutorial. This tutorial guides you through each step of the online prior authorization request process.
  • Note: Please provide as much relevant medication information as possible. This will increase the accuracy of your submission. Incomplete forms will not be processed.


Call PerformRx at 1-866-610-2773.