MedImpact Prior Authorization Request Form

The MedImpact Prior Authorization Request Form is used when the provider requests special consideration on behalf of an AHCCCS Fee-For-Service (FFS) recipient for a non-covered medication, as indicated by the AHCCCS FFS Formulary. This form applies to AHCCCS FFS recipients only and is not valid for recipients enrolled in any of the AHCCCS Managed Care Plans.

FFS Medication Request Form [PDF]


After faxing the Prior Authorization request form above, you may contact MedImpact directly at 1-800-788-2949 to follow up. Prior authorizations can not be performed over the phone. All requests must be faxed.

Please allow at least 24 hours for your request to be processed. Incomplete requests may delay this process.


Adobe Acrobat Reader is required to view PDF files. This is a free program available from the Adobe web site. Follow the download directions on the Adobe web site to get your copy of Adobe Acrobat Reader.