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Michigan Community Plan Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select

Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select

Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.

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  • Medicaid Synagis Authorization Request Form - Community Plan

    Last Published 06.30.2021

    Synagis,
  • Opioid Products (Michigan) Prior Authorization Form - Community Plan

    Last Published 08.17.2021

    Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, Zohydro ER, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Duragesic, Conzip, buprenorphine patch, Belbuca, Butrans Butorphanol, codeine, acetaminophen-codeine, butalbital-acetaminophen-caffeine-codeine, Fioricet-codeine, butalbital-aspirin-caffeine-codeine, morphine, hydrocodone-acetaminophen, Lortab, hydrocodone-ibuprofen, Dilaudid, hydromorphone, oxycodone, Roxicodone, Oxaydo, oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, oxycodone-aspirin, oxymorphone, pentazocine-naloxone, Ultram, tramadol, Ultracet, tramadol-acetaminophen, Qdolo, Nucynta, meperidine, levorphanol, acetaminophen-caffeine-dihydrocodeine, Trezix, Apadaz, benzhydrocodone-acetaminophen, Demerol, Opana, Actiq, fentanyl lozenge, Fentora, fentanyl citrate buccal ,