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Get Chn Medimpact Pa Form

In M. Lee Instructions: This form is to be used by participating physicians and providers to request coverage for drugs requiring prior authorization for clients with no other third party prescription coverage. For all drugs designated as prior authorization required (PAR) or non-formulary (NF) complete this form and fax to MedImpact Healthcare Systems, Inc. at (858) 790-7100 or for urgent requests call (800) 788-2949 with this information. Approval or denial of requests will require up to 3 wo.

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