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Pharmacy Prior Authorization Forms

Providers are responsible for obtaining prior authorization. Providers may not bill members 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

Online: Online prior authorization request form
Phone: Call 1-888-602-3741
Fax: To PerformRx at 1-855-811-9332

Effective September 1, 2019, injectable medications requiring prior authorization through the AmeriHealth Caritas District of Columbia Utilization Management department will transition to requiring prior authorization through the plan’s Pharmacy Services department.

View list of HCPCS codes for medications that require prior authorization (PDF)

Other prior authorization forms:

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

Find a snapshot of helpful information regarding prior authorizations: