You are invited to participate in a survey regarding your experience using the AHCCCS
website. This survey will take approximately two minutes. Your responses will help
us ensure that you have a high quality experience.
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.
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
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.