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Prior Authorization 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.

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 Authorizatio Portal

UM criteria selection

UM criteria selection

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