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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 858-790-7100. 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)
Afrezza
(human insulin regular)
Alogliptan benzoate
(alogliptan benzoate)
Ambien2
(zolpidem)
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)
Avita1
(tretinoin)
Axert2
(almotriptan)
Axiron
(testosterone)
Basaglar Kwikpen
(insulin glargine, hum.rec. anlog)
Belsomra
(suvorexant)
Botox
(botulinum toxin A)
Briviact
(brivaracetam)
Bydureon2
(exenatide microspheres)
Byetta2
(exenatide)
Celexa2
(citalopram)
Cerezyme
(imiglucerase)
Cialis1
(tadalafil)
ciclodan 8% solution
(ciclopirox)
Cimzia
(certolizumab pegol)
Cinryze
(C1 Inhibitor (human))
clindamycin/tretinoin
(clindamycin/tretinoin)
Compound Exceptions
Corlanor
(ivabradine hcl)
Cosentyx
(secukinumab)
Cuprimine
(penicillamine)
Cymbalta2
(duloxetine)
Daklinza
(daclatasvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Daraprim
(pyrimethamine)
Delatestryl
(testosterone)
Depen
(penicillamine)
Depo-Testosterone
(testosterone)
Dermapak Plus
(tretinoin 0.025%)
Diabetic Test Strips
Differin1
(adapalene)
Duexis
(ibuprofen/ famotidine)
Durlaza
(aspirin ER)
Dysport
(abobotulinum toxin A)
Edluar2
(zolpidem)
Effexor/XR2
(venlafaxine)
Egrifta
(tesamorelin)
Elelyso
(taliglucerase)

Elidel
(pimecrolimus)

Enbrel
(etanercept)
Entresto
(sacubitril/ valsartan)
Epclusa
(sofosbuvir/ velpatasvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Epiduo1
(adepalene/ benzoyl peroxide)
Epiduo Forte
(adapalene/ benzoyl peroxide)
Epogen
(epoetin alpha)
Esomeprazole magnesium
(esomeprazole magnesium)
Evzio
(naloxone HCl)
Eylea
(aflibercept)
Fabior
(tazarotene)
fentora
(fentanyl citrate)
Fetzima2
(levomilnacipran hydrochloride)
Fluoxetine 60mg tabs
(fluoxetine)
Follistim AQ2
(follitropin beta)
Formulary Exception Request Form
Forteo
(teriparatide)
Fortesta
(testosterone)
Frova2
(frovatriptan)
Fulyzaq2
(crofelemer)
Gattex
(teduglutide)
Genotropin
(somatropin)

Glumetza
(metformin)
Harvoni
(ledipasvir/ sofosbuvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Hetlioz
(tasimelteon)
Humatrope
(somatropin)
Humira
(adalimumab)
Ilaris
(canakinumab)
Imitrex tabs2
(sumatriptan)
Increlex
(mecasermin recombinant)

Injectable MRF

Intermezzo2
(zolpidem tartrate subl tab)
Irenka
(duloxetine)
itraconazole
(itraconazole)
Jublia
(efinaconazole)
Kalydeco
(ivacaftor)
Kerydin
(tavaborole)
Khedezla2
(desvenlafaxine)
Kineret
(anakinra)
Lazanda
(fentanyl citrate)
Levitra1
(vardenafil)
Lexapro2
(escitalopram)
Lipitor
(atorvastatin)
Lumizyme
(alglucosidase alfa)
Lunesta2
(eszopiclone)
Luvox CR2
(fluvoxamine)
Lyrica2
(pregabalin)
Maxalt/ MLT2
(rizatriptan; oral disintegrating tablet)
modafinil
(modafinil)
Myobloc
(botulinum toxin B)
Myozyme
(alglucosidase)
Mytesi
(crofelemer)
Natesto
(testosterone, nasal gel)

Nesina2
(alogliptin benzoate)

Nexium
(esomeprazole)
Norditropin/ Nordiflex
(somatropin)
Novolog/Mix 70/30
(insulin aspart)
Novolin N/R/70/30
(human insulin)
Nplate
(romiplostim)
Nuplazid
(pimavanserin tartrate)
Nutropin/ AQ/ AQ Nuspin
(somatropin)
Nuvigil
(armodafinil)
Ocaliva
(obethicholic acid)
Olysio
(simeprevir sodium)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
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)
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)

Retin-A/ Micro1
(tretinoin)

Rexulti
(brexpiprazole)
Rozerem2
(ramelteon)
Rytary
(carbidopa/ levodopa)

Saizen
(somatropin)

Sarafem2
(fluoxetine)
Savella
(milnacipran)
Selfemra2
(fluoxetine)
Serostim
(somatropin)
Silenor 2
(doxepin)
Simponi
(golimumab)
Soliris
(eculizumab)
Solodyn
(minocycline)
Sovaldi
(sofosbuvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Sonata2
(zaleplon)
Sporanox
(itraconazole)
Staxyn1
(vardenafil)
Stelara
(ustekinumab)
Stendra1
(avanfil)
Striant
(testosterone)
Subsys
(fentanyl citrate spray)
Synagis
(palivizumab)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Syprine
(trientine hydrochloride)
Taltz
(ixekizumab)
Tanzeum
(albiglutide)
Tazorac1
(tazarotene)
Technivie
(ombitasvir/
paritaprevir/ ritonavir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Testim
(testosterone 1%)
Tev-Tropin
(somatropin)
Tresiba
(insulin degludec)
Tresiba Flextouch
(insulin degludec)
Tretin-X1
(tretinoin)

tretinoin1

Treximet
(sumatriptan/
naproxen)
Trintellix2
(vortioxetine hydrobromide)
Trulicity
(dulaglutide)
Uptravi
(selexipag)
Viekira Pak
(ombitasvir/
paritaprevir/ ritonavir/ dasabuvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Veltin1
(clindamycin/tretinoin)
Venlafaxine ER
(venlafaxine er)
Viagra 1
(sildenafil)
Victoza 2
(liraglutide)
Viibryd 2
(vilazodone)
Vimovo (naproxen/ esomeprazole mag)
Vivlodex
(meloxicam)
Vogelxo
(testosterone)
Vpriv
(velaglucerase alfa)
Vraylar
(cariprazine)
Wellbutrin/ SR/ XL2
(bupropion/
bupropion ER)
Xeljanz
(tofacitinib citrate)
Xeomin
(incobotulinum toxin A)
Xgeva
(denosumab)
Xolair
(omalizumab)
Xtampza ER
(oxycodone myristate)
Xultophy
(insulin degludec/ liraglutide)
Zemaira
(alpha 1-proteinase inhibitor)
Zembrace
(sumatriptan- subcutaneous)
Zepatier
(elbasvir/ grazoprevir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Ziana1
(tretinoin)
Zinbryta
(daclizumab)
Zohydro ER
(hydrocodone
bitartrate)
Zoloft2
(sertraline)
Zolpimist2
(zolpidem)
Zomig/ ZMT2
(zolmatriptan)
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


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