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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)
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)
  • 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%)
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)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
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)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Hemangeol3
(propranolol HCL)
  • 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)

Ingrezza4
(valbenazine tosylate)

Injectable MRF

Intermezzo2
(zolpidem tartrate subl tab)
Irenka
(duloxetine)
itraconazole
(itraconazole)
Jublia
(efinaconazole)
Kalydeco
(ivacaftor)
Kerydin
(tavaborole)
Keveyis3
(dichlorphenamide)
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)
  • 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)
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)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Sonata2
(zaleplon)
Sporanox
(itraconazole)
Staxyn1
(vardenafil)
Stelara
(ustekinumab)
Stendra1
(avanfil)
Striant
(testosterone)
Striverdi Respimat3
(olodaterol)
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)
Trulance
(plecanatide)
Trulicity
(dulaglutide)
Tuzistra XR3
(chlorpheniramine/ codeine)
Tymlos4
(abaloparatide)
Uptravi
(selexipag)
Viekira Pak
(ombitasvir/
paritaprevir/ ritonavir/ dasabuvir)
  • MRF (Non-MA providers)
  • MA Standard PA form (Coming soon)
  • Criteria
Velphoro3
(sucroferric oxyhydroxide)
  • 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)
Vraylar
(cariprazine)
Wellbutrin/ SR/ XL2
(bupropion/
bupropion ER)
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)
  • 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)
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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