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.
MedImpact standard Medication Request Forms.
State-specific Prior Authorization forms.
Health Care Providers
Prior Authorization 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
Adobe Acrobat Reader is required to view the documents.