Prior Authorization and Medication Request Documents

MedImpact standard Medication Request forms

• MedImpact Standard MRF
• MedImpact Medicare Part D Coverage Determination Request Form

State-specific Prior Authorization and Medication Request forms

Arizona

• Arizona State PA Form

California

• California State PA Form

Colorado

• Colorado Serious Mental Illness Step Therapy Exception Form
• Colorado State PA Form

Florida

• Florida State PA Form

Illinois

• Illinois Medicaid State PA form
• Illinois State PA form

Indiana

• Indiana State Medicaid PA Form
• Indiana State PA Form

Iowa

• Iowa State Medicaid PA Form

Kentucky

• Kentucky Medicaid PA Form

Louisiana

• Louisiana State PA Form

Massachusetts

• Massachusetts State Hepatitis C PA Form
• Massachusetts State PA Form
• Massachusetts State Synagis PA Form

Michigan

• Michigan State PA Form

Minnesota

• Minnesota State Medicaid PA Form
• Minnesota State PA Form

New Mexico

• New Mexico Medication Request Form

New York

• New York State Medicaid PA Form

Oregon

• Oregon State PA Form

Texas

• 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:

• CoverMyMeds ePA portal
• Surescripts Prior Authorization Portal

UM criteria selection

• UM criteria selection

Adobe Acrobat Reader is required to view the documents.

• Download Adobe Acrobat