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 Medicare Part D Coverage Determination Request Form
Colorado Serious Mental Illness Step Therapy Exception Form
Illinois Medicaid State PA form
Indiana State Medicaid PA Form
Massachusetts State Hepatitis C PA Form
Massachusetts State Synagis PA Form
Minnesota State Medicaid PA Form
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:
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