Prior Authorization
Physicians seeking prior authorization for medications that are not listed on the formulary or are listed with a Prior Authorization (PA) requirement are required to submit a Medication Request Form (MRF) to MedImpact. There are three different Medication Request Forms: Standard Form, COX-2 Inhibitors Form, and Proton Pump Inhibitors Form. Physicians are notified by MedImpact if their medication request is approved or denied.
Prescribers can download these forms and save them on their own computer systems for future use. Please see the instructions for saving pdf medication request forms. These forms are offered in two formats:
- Basic PDF Form
- Fill-In PDF Form
For completion by hand. To use this form, first print the form, complete it with a pen, and fax the completed form to MedImpact at the number provided on the form.
For completion using the keyboard. To use this form, use the computer keyboard to complete each field on the form, print the completed form, and fax the completed form to MedImpact at the number provided on the form. Use the "Reset Form" button to clear the form for next use. (NOTE: Completed forms cannot be saved electronically. You may only print the completed form.)