MedImpact Prior (Rx) Authorization Form

Updated January 23, 2022

A MedImpact prior authorization form is used when the client in question is seeking a non-conventional prescription or one which is not on the preferred drug list. By filling out and delivering a prior authorization form, the physician is able to request coverage. For your convenience, the prior authorization form for MedImpact has been provided below.

  • Fax: 1 (800) 788-2949
  • Phone: 1 (858) 790-7100

By State

How to Write

Step 1 – In the Submission section, fill out the name of the person that you are submitting this form to, including their phone number, fax number, and date.

Step 2 – Tick the box in the Review section if you are requesting an urgent review and write your signature in the blank field.

Step 3 – Fill out the Patient Information box, by providing the patient’s full name, their date of birth, their gender, their complete address, their issuer’s number (if different from that given in the Submission section), their member/Medicaid number, their group number, their BIN number (if applicable), their PCN number (if applicable), and their Rx ID number (if applicable).

Step 4 – In the Prescriber Information section, you must provide your name, your NPI number, your specialty, your complete address, your phone number, your fax number, the name of the office contact, and their phone number.

Step 5 – Complete the Prescription Drug Information box by filling out the requested drug name, its strength, the route of administration, the quantity, the day’s supply, the expected duration of therapy, and whether this is new or continued therapy. If this is a provider-administered drug, you will need to enter the appropriate HCPCS Code, the NDC number, and the dose per administration.

Step 6 – If this is a compound drug that you are requesting, you will need to list the compound drug name in the Prescription Compound Drug Information section, followed by the name, NDC number, and quantity of each ingredient.

Step 7 – If you are requesting a device, enter the device name, expected duration of use, and the relevant HCPCS code (if applicable) into the Prescription Device Information section.

Step 8 – In the Patient Clinical Information section, you will need to enter the patient’s related diagnosis, ICD version, and ICD code, followed by the drug name, strength, frequency, duration of use, and reason for the failure of use for each applicable drug. Below that, enter any known drug allergies, as well as the height and weight of the patient (if available).

Step 9 – Finally, you must describe your justification for making this request in the blank Justification field.