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Medication Request Forms (MRF) 
Harvard Pilgrim’s prior authorization program ensures that our members are using the safest and most cost-effective medications for their condition. 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: The following drugs/drug classes should be submitted on the designated drug-specific form, listed below (NH providers excluded): Hepatitis C
(Epclusa, Daklinza, Harvoni, Mavyret, Olysio, Sovaldi, Viekira Pak/XR, Vosevi, Zepatier)
Clinical Criteria
Medications requiring prior authorization have clinical guidelines developed by licensed clinical pharmacists, which reflect the latest in evidence-based medicine and are used as a tool to promote quality, safety, and cost-effective pharmacotherapy. Harvard Pilgrim makes our clinical criteria available to physicians, as a reference. You can find our clinical criteria below, listed alphabetically by drug name.
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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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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