Prior Authorization and Medication Request forms
The Medication Request Form (MRF) is submitted by participating physicians and providers to obtain coverage for formulary drugs requiring prior authorization (PA); non-formulary drugs for which there are no suitable alternatives available; and overrides of pharmacy management procedures such as step therapy, quantity limit or other edits.
MedImpact standard Medication Request forms
State-specific Prior Authorization and Medication Request forms
- Arizona State PA Form
- California State PA Form
- Colorado Serious Mental Illness Step Therapy Exception Form
- Colorado State PA Form
- Florida State PA Form
- Illinois Medicaid State PA form
- Illinois State PA form
- Indiana State Medicaid PA Form
- Iowa State Medicaid PA Form
- Kentucky Medicaid PA Form
- Louisiana State PA Form
- Massachusetts State Hepatitis C PA Form
- Massachusetts State PA Form
- Massachusetts State Synagis PA Form
- Michigan State PA Form
- Minnesota State Medicaid PA Form
- Minnesota State PA Form
- New Mexico Medication Request Form
- Oregon State PA Form
- Texas State PA Form
Health Care Providers
Prior Authorization Submission
FAX (858)790-7100
ePA submission
Conveniently submit requests at the point of care through the patient’s electronic health record.
If the EMR/EHR does not support ePA, you can use one of these vendor portals:
UM criteria selection
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