Pharmacy Prior Authorization

Providers are responsible for obtaining prior authorization. Providers may not bill members for services that require prior authorization for which authorization was not obtained.

Authorization is not a guarantee of payment. Other limitations or requirements may apply.

  1. Submit authorization requests to the PerformRxSM Prior Authorization team by fax at 1-855-825-2717. For any questions, call PerformRx at 1-855-371-3963.
  2. To submit requests for medication with Healthcare Common Procedure Coding System (HCPCS) codes that require authorization, the HCPCS code that corresponds to the medication should be included in the request. If the HCPCS code is a miscellaneous code, the NDC (National Drug Code) number must also be included on the request.

Pharmacy Prior Authorization Forms

AHCA authorization forms:

Pharmacy prior authorization forms: You may use an AHCA form if there is no matching PerformRx form listed above. These forms should still be submitted to PerformRx.