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
Prior authorizations for injectable medications
Effective May 26, 2020, reimbursement for administration of designated drugs at a hospital-based facility is available only if specific criteria are met. These drugs, which are highlighted in blue in the HCPCS Medication Codes list below, can be safely administered in an in-network infusion center, network provider office, or home setting. Providers must receive prior authorization for the administration of these drugs. Please refer to the Site of Care Policy for more information.
Note: Medications requiring a site requirement are highlighted.
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.
Other prior authorization forms:
- HCPCS Authorization Form (PDF)
- Hepatitis C prior authorization criteria (PDF)
- Opioid-containing products request form (PDF)
- Specialty prior authorization forms
Use this pharmacy reference guide for information regarding pharmacy provider services:
Find a snapshot of helpful information regarding prior authorizations: