Prescription Drug Prior Authorization or Step Therapy Exception Request Form

Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members. Fax to MedImpact at (858) 790-7100. For any questions, contact MedImpact at (800) 788-2949.

For prescription drug prior authorization requests for Medi-Cal members, refer to www.Medi-CalRx.dhcs.ca.gov.

Haga clic en la imagen debajo para abrir el archivo en PDF: