Pharmacy Prior Authorization Forms

Providers are responsible for obtaining prior authorization. Providers may not bill enrollees for services that require prior authorization for which the authorization was not obtained, resulting in denial of the claim.

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

How to submit a request for prior authorization

To submit electronically, please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software or either of the following online portals:

• CoverMyMeds
• Surescripts

Phone: Call 1-855-332-0992
Fax: To PerformRx^℠ at 1-844-480-2486 (standard fax) or 1-855-350-0284 (urgent fax)

Other prior authorization forms:

• Universal Pharmacy Prior Authorization Form (PDF)
• HCPCS Authorization Form (PDF)

Use this pharmacy reference guide for information regarding pharmacy provider services:

• Pharmacy reference guide (PDF)

Find a snapshot of helpful information regarding prior authorizations:  

• Prior authorization quick fact sheet (PDF)
• Prior authorization criteria (PDF)