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Pharmacy Prior Authorization Form

Save time and reduce paperwork with PerformRx's Online Prior Authorization Form!

Submit Online Prior Authorization Form

Having trouble using the online form? Download the printable Prior Authorization form.

What is this?

It's a prior authorization request form you complete online. Fill it out and your PA requests are instantly submitted to PerformRx.

What are the benefits?

Save time by: 

  • Reducing prior authorization review time
  • Giving instant approvals for specific drugs
  • Attaching member-specific documents such as labs, chart notes, consults and more (formats: pdf, doc, xls, ppt, txt)
  • Saving unique provider information to speed up future submissions
  • Printing a summary page for easy reference 

Ready to get started?

Take our online PA tutorial. It guides you through each step of the online PA request process. Start using this form today and streamline your PA requests.

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


Contact 1-800-588-6767 for help. We look forward to serving your Next Generation Pharmacy Benefit Management Needs.

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