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MedImpact Prior (Rx) Authorization Form

MedImpact Prior (Rx) Authorization Form

Updated July 27, 2023

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

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