The Medication Request Form 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 Forms
California State PA Form
Colorado State PA Form
Indiana State Medicaid PA Form
Indiana 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 York State Medicaid PA Form
Oregon State PA Form
Texas State PA Form

Health Care Providers
Prior Authorization submission: Fax 858-790-7100

UM Criteria selection

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