Pharmacy Prior Authorization Forms
The file(s) below are in PDF format.
Pharmacy Prior Authorization Contact Information
Pharmacy Benefit Drugs (MedImpact):
Phone: (800) 210-7628
Prior Authorization Call Center: (844) 336-2676
Drug PA Fax: (858) 357-2612
Physician Administered Drugs (Passport):
If requesting a medical benefit billed drug, please include the appropriate HCPCS code on the form.
Phone: (800) 578-0775
PAD PA Fax: (844) 802-1406