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Medication Prior Authorization Program (including Step Therapy)

The Medication Prior Authorization Program helps to ensure appropriate use of medications. We do this so that our members can have continued access to certain costly medications. Download Medication Request Forms (MRF) and Clinical Criteria.

Medication Request Forms (MRF) should be submitted by physician providers to obtain coverage for drugs requiring prior authorization. Please complete the appropriate form and fax back 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.

Clinical criteria
To discuss the clinical criteria used to determine authorization of these medications, please contact Pharmacy Services at 1-617-509-9060

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Medication Request Forms and Clinical Criteria

Quantity limitations

Not available through the Mail Service Program

Medications not covered