Pharmacy Prior Authorization Form

Save time and reduce paperwork by using the PerformRxâ„  online prior authorization form.

Submit an Online Prior Authorization Form

If you’re having trouble, download the printable Prior Authorization form (PDF).

What is it?

It’s an online prior authorization request that gets instantly submitted to PerformRx.

What are the benefits?

  • Reduce review time.
  • Get instant approvals for specific drugs.
  • Attach member-specific documents such as labs, chart notes, consults and more.
    (The accepted formats for attachments are PDF, DOC, XLS, PPT and TXT.)
  • Save unique provider information to expedite future submissions.
  • Print a summary of the request for easy reference.

Ready to get started?

Please provide as much relevant medication information as possible to increase the accuracy of your submission. Incomplete forms will not be processed.


The online prior authorization submission tutorial guides you through every step of the process. You can also call 1-866-610-2774 for help.