Pharmacy Forms and Manuals

Pharmacy Forms and Manuals

Coverage Redetermination

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.

Retroactive prior authorization requests (PA requests dated before 1/1/2023) should be faxed to (909) 890-5766.

Drug Request

Mail Order


Other Pharmacy Provider Forms

WIC Program Forms (California Department of Public Health)



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Information on this page is current as of June 12, 2024