CVS Caremark's general (global) request for prior authorization or formulary exception for commercial (non-Medicare) prescription benefit plans.
- Completed by
- Prescriber
- Issued by
- CVS Caremark
- Format
- Fillable PDF
- Language
- English
MedImpact Standard Medication Request Form (MRF)
MedImpact, a pharmacy benefit manager, uses its Standard Medication Request Form (MRF) for prescriber requests for prior authorization, continuation of therapy, compounds, quantity limit exceptions and brand-name (DAW) coverage for commercial members. A prescriber meets it when a MedImpact-managed plan rejects or limits a prescription. The one-page form requires the prescriber's signature, confirming the information can be verified in patient records.
Who completes it
Only the prescriber completes and signs it. If someone other than the patient or prescriber is the requestor, the form asks for their name and relationship to the enrollee.
Submitting and payment
- How to submit it
- Submit electronically from the patient's EHR, or through the CoverMyMeds or Surescripts portals if the EHR lacks ePA, or fax the form to MedImpact.
Good to know
- Quantity limit reasons include titration, failure at the plan's limit, inability to consolidate doses, unavailable strength, and insulin with total daily units.
- Brand requests ask about allergic reactions to at least one generic manufacturer, or failure with two, and whether a MedWatch form was submitted.
- Medicare Part D requests use MedImpact's separate Coverage Determination Request Form, not the MRF.
- MedImpact posts state-mandated forms for about 20 states, including Colorado, Massachusetts, New York and Texas, on the same page.
Get the official form
Download the current version from the source each time; forms change without notice.
Prior Authorization Request Form (MedImpact Standard Medication Request Form)
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Who can submit a MedImpact Medication Request Form?
The form states it is to be used by prescribers only and requires the prescriber's signature. By signing, the prescriber confirms the information is accurate and can be verified by patient records. A representative's name and relationship to the enrollee is asked when the requestor is not the patient or prescriber.
How do I mark a MedImpact request as urgent?
Check the Urgent box near the bottom of the form before signing. The form also asks for clinical history, listing drugs tried with strength, dates of use and adverse reaction or failure, plus supporting information such as lab values, contraindications, allergies, height and weight.