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.

MedImpact Standard MRF

MedImpact Medicare Part D Coverage Determination Request Form

State-specific Prior Authorization and Medication Request forms.

Arizona State PA Form

California State PA Form

Colorado State PA Form

Colorado Serious Mental Illness Step Therapy Exception Form

Kentucky Medicaid PA Form

Illinois State PA form

Illinois Medicaid State PA form

Indiana State Medicaid PA Form

Iowa State Medicaid PA Form

Florida State 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

New York State Medicaid PA 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:

CoverMyMeds ePA portal

Surescripts Prior Authorization Portal

UM criteria selection

UM criteria selection

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