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Medication Request Forms (MRF) and Clinical Coverage Criteria

Beginning November 2016, Massachusetts providers should use the Massachusetts Standard Form for Medication Prior Authorization Requests to request coverage for most drugs that require prior authorization. Please refer to our drug specific criteria for details related to required information.

Providers in all other service states should continue to use the drug-specific Medication Request Forms (MRF). Completed forms should be faxed to MedImpact Healthcare Systems at 888-807-6643. If you have any questions regarding this process, please contact MedImpact's Customer Service at 800-788-2949.

Please note: Criteria are applicable for Commercial members, except as indicated.

Medication
Medication Request Forms* (MRF) and
Clinical Coverage Criteria*
Abstral
(fentanyl citrate)
Actemra
(tocilizumab)
Acthar
(corticotropin)
Actiq
(fentanyl citrate)
Addyi
(flibanserin)
Adcirca
(tadalafil)
Adlyxin
Afrezza
(human insulin regular)
AirDuo Respiclick4
(fluticasone/salmeterol)
Aktipak4
(erythromycin/benzoyl peroxide)
Akynzeo3
(netupitant/ palonosetron)
Alogliptan benzoate
(alogliptan benzoate)
Ambien2
(zolpidem)
Alunbrig 4
(brigatinib)
Ambien CR2
(zolpidem CR)
Amerge2
(naratriptan)
Androderm
(testosterone transdermal)
Androgel
(testosterone 1%)
Aplenzin
(bupropion)
Aralast
(alpha 1-proteinase
inhibitor)
Aranesp
(darbepoetin)
Armodafinil
(armodafinil)
Atralin1
(tretinoin topical)
Austedo4
(deutetrabenazine)
AUVI-Q
(epinephrine)
Avita1
(tretinoin)
Axert2
(almotriptan)
Axiron
(testosterone)
Basaglar Kwikpen
(insulin glargine, hum.rec. anlog)
Belsomra
(suvorexant)
Bepreve3
(bepotastine besilate)
Botox
(botulinum toxin A)
Briviact
(brivaracetam)
Bydureon2
(exenatide microspheres)
Byetta2
(exenatide)
Carac3
(fluorouracil)
Celexa2
(citalopram)
Cialis1
(tadalafil)
ciclodan 8% solution
(ciclopirox)
Cimzia
(certolizumab pegol)
Cinryze
(C1 Inhibitor (human))
clindamycin/tretinoin
(clindamycin/tretinoin)
Compound Exceptions
Corlanor
(ivabradine hcl)
Cosentyx
(secukinumab)
Cresemba3
(isavuconazonium sulfate)
Cuprimine
(penicillamine)
Cymbalta2
(duloxetine)
Daklinza
(daclatasvir)
Daraprim
(pyrimethamine)
Delatestryl
(testosterone)
Depen
(penicillamine)
Depo-Testosterone
(testosterone)
Dermapak Plus
(tretinoin 0.025%)
Dexilant3
(dexlansoprazole)
Diabetic Test Strips
Diclofenac sodium
Differin1
(adapalene)
Duavee3
(conjugated estrogens/ bazedoxifene)
Duexis
(ibuprofen/ famotidine)
Dupixent
(dupilumab)
Durlaza
(aspirin ER)
Dysport
(abobotulinum toxin A)
Edluar2
(zolpidem)
Effexor/XR2
(venlafaxine)
Egrifta
(tesamorelin)

Elidel
(pimecrolimus)

Emflaza
(deflazacort)
Enbrel
(etanercept)
Entresto
(sacubitril/ valsartan)
Epclusa
(sofosbuvir/ velpatasvir)
Epiduo1
(adepalene/ benzoyl peroxide)
Epiduo Forte
(adapalene/ benzoyl peroxide)
Epogen
(epoetin alpha)
Ertaczo3
(sertaconazole)
Esomeprazole magnesium
(esomeprazole magnesium)
Eucrisa4
(crisabarole)
Evzio
(naloxone HCl)
Eylea
(aflibercept)
Fabior
(tazarotene)
Farxiga3
(dapagliflozin propanediol)
fentora
(fentanyl citrate)
Fetzima2
(levomilnacipran hydrochloride)
Fluoroplex3
(fluorouracil)
Fluorouracil3
Fluoxetine 60mg tabs
(fluoxetine)
Follistim AQ2
(follitropin beta)
Formulary Exception Request Form
Forteo
(teriparatide)
Fortesta
(testosterone)
Frova2
(frovatriptan)
Gattex
(teduglutide)
Genotropin
(somatropin)

Glumetza
(metformin)
Harvoni
(ledipasvir/ sofosbuvir)
Hemangeol3
(propranolol HCL)
Hetlioz
(tasimelteon)
Humatrope
(somatropin)
Humira
(adalimumab)
Ilaris
(canakinumab)
Imitrex tabs2
(sumatriptan)
Increlex
(mecasermin recombinant)

Ingrezza4
(valbenazine tosylate)

Injectable MRF

Intermezzo2
(zolpidem tartrate subl tab)
Irenka
(duloxetine)
itraconazole
(itraconazole)
Jublia
(efinaconazole)
Kalydeco
(ivacaftor)
Kerydin
(tavaborole)
Keveyis3
(dichlorphenamide)
Kevzara4
(sarilumab)
Khedezla2
(desvenlafaxine)
Kineret
(anakinra)
Kisqali
(ribociclib succinate)
Kisqali Femara Co-Pack
(ribociclib succinate/letrozole)
Lazanda
(fentanyl citrate)
Levitra1
(vardenafil)
Lexapro2
(escitalopram)
Lipitor
(atorvastatin)
Lunesta2
(eszopiclone)
Luvox CR2
(fluvoxamine)
Luzu3
(luliconazole)
Lyrica2
(pregabalin)
Maxalt/ MLT2
(rizatriptan; oral disintegrating tablet)
Mentax3
(butenafine)
Minitran3
(nitroglycerin)
Mircera
(methoxy peg-epoetin beta)
Mirvaso3
(brimonidine tartrate)
modafinil
(modafinil)
Myobloc
(botulinum toxin B)
Mytesi
(crofelemer)
Natesto
(testosterone, nasal gel)
Neo-Synalar3
(neomycin/fluocinolone)

Nesina2
(alogliptin benzoate)

Nexium
(esomeprazole)
Norditropin/ Nordiflex
(somatropin)
Novolog/Mix 70/30
(insulin aspart)
Novolin N/R/70/30
(human insulin)
Nuplazid
(pimavanserin tartrate)
Nutropin/ AQ/ AQ Nuspin
(somatropin)
Nuvigil
(armodafinil)
Ocaliva
(obethicholic acid)
Olysio
(simeprevir sodium)
Omnitrope
(somatropin)
Onfi
(clobazam)
Onglyza2
(saxagliptin)
Onmel
(itraconazole)
Onzetra Xsail
(sumariptan succinate)
Orencia
(abatacept)
Orkambi
(lumacaftor/ ivacaftor)
Otezla
(apremilast)
Paxil/ CR2
(paroxetine)
Pedipirox-4
(ciclopirox 8.0% solution)
Penlac
(ciclopirox)
Pennsaid
(diclofenac sodium)
Pexeva2
(paroxetine)
Picato3
(ingenol mebutate)
Plegridy3
(peginterferon beta-1A)
Plegridy Pen3
(peginterferon beta-1A)
Praluent
(alirocumab)

Pristiq2
(desvenlafaxine)
Procrit
(epoetin alpha)
Prolastin
(alpha 1-proteinase inhibitor)
Prolia
(denosumab)
Protopic
(tacrolimus)
Provigil
(modafinil)
Prozac/ Weekly2
(fluoxetine/ fluoxetine hcl)
Rayaldee
(calcifediol)
Rayos
(prednisone)
Relistor
(methylnaltrexone)
Repatha
(evolocumab)

Revatio
(sildenafil citrate)
Rescula
(unoprostone isopropyl)

Retin-A/ Micro1
(tretinoin)

Rexulti
(brexpiprazole)
Rhofade
(oxymetazoline hcl)
Rozerem2
(ramelteon)
Rydapt4
(midostaurin)
Rytary
(carbidopa/ levodopa)

Saizen
(somatropin)

Sarafem2
(fluoxetine)
Savella
(milnacipran)
Selfemra2
(fluoxetine)
Serostim
(somatropin)
Silenor 2
(doxepin)
Siliq4
(broadalumab)
Simponi
(golimumab)
Sirturo3
(bedaquiline fumarate)
Solaraze3
(diclofenac sodium)
Soliqua
Solodyn
(minocycline)
Sovaldi
(sofosbuvir)
Sonata2
(zaleplon)
Sporanox
(itraconazole)
Staxyn1
(vardenafil)
Stelara
(ustekinumab)
Stendra1
(avanfil)
Striant
(testosterone)
Striverdi Respimat3
(olodaterol)
Subsys
(fentanyl citrate spray)
Synagis
(palivizumab)
Syprine
(trientine hydrochloride)
Taltz
(ixekizumab)
Tanzeum
(albiglutide)
Tazorac1
(tazarotene)
Technivie
(ombitasvir/
paritaprevir/ ritonavir)
Testim
(testosterone 1%)
Tev-Tropin
(somatropin)
Tresiba
(insulin degludec)
Tresiba Flextouch
(insulin degludec)
Tretin-X1
(tretinoin)

tretinoin1

Treximet
(sumatriptan/
naproxen)
Trintellix2
(vortioxetine hydrobromide)
Trulance
(plecanatide)
Trulicity
(dulaglutide)
Tuzistra XR3
(chlorpheniramine/ codeine)
Tymlos4
(abaloparatide)
Uptravi
(selexipag)
Viekira Pak
(ombitasvir/
paritaprevir/ ritonavir/ dasabuvir)
Velphoro3
(sucroferric oxyhydroxide)
Veltin1
(clindamycin/tretinoin)
Venlafaxine ER
(venlafaxine er)
Viagra 1
(sildenafil)
Victoza 2
(liraglutide)
Viibryd 2
(vilazodone)
Vimovo (naproxen/ esomeprazole mag)
Vivlodex
(meloxicam)
Vogelxo
(testosterone)
Vraylar
(cariprazine)
Wellbutrin/ SR/ XL2
(bupropion/
bupropion ER)
Xadago4
(safinamide mesylate)
Xeljanz
(tofacitinib citrate)
Xeomin
(incobotulinum toxin A)
Xermelo
(telotristat etiprate)
Xgeva
(denosumab)
Xigduo XR3
(dapagliflozin/metformin HCL)
Xolair
(omalizumab)
Xtampza ER
(oxycodone myristate)
Xultophy
(insulin degludec/ liraglutide)
Zejula4
(niraparib tosylate)
Zemaira
(alpha 1-proteinase inhibitor)
Zembrace
(sumatriptan- subcutaneous)
Zepatier
(elbasvir/ grazoprevir)
Ziana1
(tretinoin)
Zinbryta
(daclizumab)
Zohydro ER
(hydrocodone
bitartrate)
Zoloft2
(sertraline)
Zolpimist2
(zolpidem)
Zomig/ ZMT2
(zolmatriptan)
Zontivity3
(vorapaxar sulfate)
Zorbtive
(somatropin)
Zurampic
(lesinurad)

Key

1 Prior Authorization is required only when quantity limitation or restriction is exceeded

2 Prior Authorization is required only when Step Therapy requirement is not met

3 Prior Authorization is required for Value formulary only

4 Prior Authorization is required for Premium formulary only


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