PerformRX Prior (Rx) Authorization Form

Updated January 24, 2022

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

How to Write

Step 1 – First fill out the patient’s full name, date of birth and ID number.

Step 2 – Next, fill in your full name (as the physician), your specialty, your phone and fax numbers, your NPI number, and your complete address.

Step 3 – Below that, you will need to provide the name and strength of the medication that you are requesting coverage for, as well as the directions for use, the anticipated length of therapy, and the related diagnosis.

Step 4 – You will then need to list any preferred medications that have been tried to treat the patient’s relevant diagnosis, listing the strength, frequency, and duration for each. You will also need to write your justification for making this request.

Step 5 – Finally, at the bottom of the form, you must provide your written signature and the date.