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PerformRX Prior (Rx) Authorization Form

A 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.
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Updated November 15, 2024

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  • 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

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