MedImpact (IEHP Medicare Line of Business's PBM) handles all Medicare pharmacy and provider prior authorization and pharmacy benefit related questions. Providers and pharmacies can call MedImpact Customer Contact Center at (800) 788-2949. Health care providers can submit prior authorizations via fax (858) 790-7100, or download forms at the MedImpact Website.
Pharmacy Forms and Manuals
Coverage Redetermination
- Request for Redetermination of Medicare Prescription Drug Denial - English (PDF) Download Request for Redetermination of Medicare Prescription Drug Denial - English (PDF)
- Request for Redetermination of Medicare Prescription Drug Denial - Spanish (PDF) Download Request for Redetermination of Medicare Prescription Drug Denial - Spanish (PDF)
- Coverage Determination Form Download Coverage Determination Form
Retroactive prior authorization requests (PA requests dated before 1/1/2023) should be faxed to (909) 890-5766.
Drug Request
- Supplemental PER Form for Compounded Prescription (PDF) Download Supplemental PER Form for Compounded Prescription (PDF)
IEHP Physician Administered Drug (PAD) Prior Authorization
- IEHP UM Referral Form (PDF) Download IEHP UM Referral Form (PDF)
Exceptions to criteria or requests for coverage of physician administered drugs may be submitted by prescribers on the Referral Form.
Mail Order
- Mail-Order Service Fax Form (PDF) Download Mail-Order Service Fax Form (PDF)
Medicare
- Hospice Form for Medicare Part D Plans (PDF) Download Hospice Form for Medicare Part D Plans (PDF)
- Medicare Prescription Drug Coverage and Your Rights - English (PDF) Download Medicare Prescription Drug Coverage and Your Rights - English (PDF)
- Medicare Prescription Drug Coverage and Your Rights - Spanish (PDF) Download Medicare Prescription Drug Coverage and Your Rights - Spanish (PDF)
Other Pharmacy Provider Forms
- CMS 1696 Appointment of Representative - English (PDF) Download CMS 1696 Appointment of Representative - English (PDF)
- CMS 1696 Appointment of Representative - Spanish (PDF) Download CMS 1696 Appointment of Representative - Spanish (PDF)
- CMS 1696 Appointment of Representative - Chinese (PDF) Download CMS 1696 Appointment of Representative - Chinese (PDF)
- CMS 1696 Appointment of Representative - Vietnamese (PDF) Download CMS 1696 Appointment of Representative - Vietnamese (PDF)
- Nutritional Evaluation Form - Adult (PDF) Download Nutritional Evaluation Form - Adult (PDF)
- Nutritional Evaluation Form - Infant (PDF) Download Nutritional Evaluation Form - Infant (PDF)
- Opioid Edit Error Report Form (PDF) Download Opioid Edit Error Report Form (PDF)
WIC Program Forms (California Department of Public Health)
- Pediatric Referral Form (PDF) Download Pediatric Referral Form (PDF)
- WIC Referral For Pregnant Women (PDF) Download WIC Referral For Pregnant Women (PDF)
- WIC Referral For Postpartum/Breastfeeding Women (PDF) Download WIC Referral For Postpartum/Breastfeeding Women (PDF)
Information on this page is current as of December 18, 2024
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader.