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PerformRX Prior (Rx) Authorization Form

PerformRX Prior (Rx) Authorization Form

Updated July 27, 2023

PerformRX prior authorization form is completed by a pharmacist to request coverage of medications not normally covered under a patient’s medical insurance plan. PerformRx is a Philadelphia, Pennsylvania-based company that works with Medicaid plans and at-risk insurance plan members to ensure effective medication treatments. Below you will find the different available forms for each associated health plan, as well as the fax and phone numbers that you will need to use.

  • Alameda Alliance (PA) Fax to: 1 (855) 811-9327 / Urgent Requests 1 (855) 851-4054
  • Alameda Alliance (PA) Phone: 1 (855) 251-0966
  • AmeriHealth (PA) Fax to: 1 (888) 981-5202 /
  • AmeriHealth (PA) Injectable Requests Phone: 1 (866) 610-2774
  • Contra Costa (CA) Fax to: 1 (866) 205-8014 / Urgent Requests 1 (866) 428-7369
  • Contra Costa (CA) Specialties & Injectables Fax to: 1 (925) 313-6412
  • Contra Costa (CA) Phone: 1 (925) 957-7260
  • Keystone First (PA) Fax to: 1 (215) 937-5018
  • Keystone First (PA) Phone: 1 (800) 588-6767
  • MDwise Fax to: 1 (855) 811-9324 / Urgent Requests: 1 (855) 811-9324
  • MDwise Phone: 1 (855) 491-0633
  • SF Health Plan Fax to: 1 (855) 811-9330 / Urgent Requests: 1 (855) 811-9331
  • SF Health Plan Phone: 1 (888) 989-0091

By State