Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
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Actemra, Subcutaneous (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Albenza (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Alinia (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Aranesp / Epogen / Procrit Initial Review (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Aranesp / Epogen / Procrit Reauthorization Review (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Benznidazole (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Calcitonin Gene-Related Peptide [CGRP] (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Carac, Efudex / Fluorouracil Cream (0.5%, 5%) (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Cayston (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Cimzia (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Claravis (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Clobetasol (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Compounds (Michigan) Prior Authorization Form - Community Plan
Last Published 06.25.2018
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Daraprim (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Desmopressin / Stimate / DDAVP (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Dovonex (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Dronabinol / Marinol (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Dry Eye Disease (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Duexis & Vimovo (Michigan) Prior Authorization Form - Community Plan
Last Published 11.19.2019
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Elidel / Protopic (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Elmiron (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Enbrel (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Endari (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Enoxaparin (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Erleada (Michigan) Prior Authorization Form - Community Plan
Last Published 10.16.2018
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Erythropoiesis Stimulating Agents [Aranesp, Epogen, Procrit, Retacrit] (Michigan) Prior Authorization Form - Community Plan
Last Published 01.30.2020
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Fentanyl Immediate-Release (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Fentanyl, Transdermal (Michigan) Prior Authorization Form - Community Plan
Last Published 10.19.2018
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Firazyr (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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Forteo (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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General Non-Preferred Medication (Michigan) Prior Authorization Form - Community Plan
Last Published 06.22.2018
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Global Quantity Limits (Michigan) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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GLP-1 Agonist (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
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GLP-1 Agonist / Basal Insulin Combinations (Michigan) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Gonadotropin-Releasing Hormone Agents [Lupron, Eligard, Trelstar, Lupaneta] (Michigan) Prior Authorization Form - Community Plan
Last Published 10.01.2018
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Granulocyte Colony-Stimulating Factor, G-CSF (Michigan) Prior Authorization Form - Community Plan
Last Published 10.29.2019
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Growth Hormone Medications, Re-Authorization Review (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Growth Hormones, Initial Review (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Humira (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Humulin R U-500 (Michigan) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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Imitrex / Sumatriptan, Non-Oral (Michigan) Prior Authorization Form - Community Plan
Last Published 07.26.2018
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Increlex (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Insulin Pen Needles and Syringes (Michigan) Prior Authorization Form - Community Plan
Last Published 02.06.2019
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Insulins (Michigan) Prior Authorization Form - Community Plan
Last Published 03.25.2019
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Iron Chelators [Exjade, Ferriprox, Jadenu] (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Isotretinoin (Michigan) Prior Authorization Form - Community Plan
Last Published 01.14.2020
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Krintafel (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Lidocaine Patch (Michigan) Prior Authorization Form - Community Plan
Last Published 01.14.2020
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Lorbrena (Michigan) Prior Authorization Form - Community Plan
Last Published 03.26.2019
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Lovaza (Michigan) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lucemyra (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Medicaid Synagis Authorization Request - Community Plan
Last Published 11.22.2019
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Mefloquine / Lariam (Michigan) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Mepron (Michigan) Prior Authorization Form - Community Plan
Last Published 05.04.2018
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Motegrity (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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MS Agents [Multiple Sclerosis] (Michigan) Prior Authorization Form - Community Plan
Last Published 04.01.2019
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Naprosyn / Naproxen Suspension (Michigan) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Neupogen (Michigan) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Nuzyra (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Ocaliva (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Octreotide / Sandostatin (Michigan) Prior Authorization Form - Community Plan
Last Published 04.26.2018
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Olumiant (Michigan) Prior Authorization Form - Community Plan
Last Published 09.19.2019
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Oncology Agents (Michigan) Prior Authorization Form - Community Plan
Last Published 11.27.2018
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Oral Contraceptives (Michigan) Prior Authorization Form - Community Plan
Last Published 04.26.2018
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Orencia, Subcutaneous (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Orilissa (Michigan) Prior Authorization Form - Community Plan
Last Published 03.25.2019
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Osphena (Michigan) Prior Authorization Form - Community Plan
Last Published 10.07.2019
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Otezla (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Praluent (Michigan) Prior Authorization Form - Community Plan
Last Published 02.07.2019
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Protopic (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Pulmonary Arterial Hypertension (PAH) (Michigan) Prior Authorization Form - Community Plan
Last Published 09.19.2019
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Pulmozyme (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Ranexa (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Rayos (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Rectiv (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Renvela (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Repatha (Michigan) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Sensipar (Michigan) Prior Authorization Form - Community Plan
Last Published 04.23.2018
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SGLT-2 Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Published 10.16.2018
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Short-Acting Opioid Products (Michigan) Prior Authorization Form - Community Plan
Last Published 10.15.2019
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Siliq (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Solaraze (Michigan) Prior Authorization Form - Community Plan
Last Published 04.23.2018
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Soriatane (Michigan) Prior Authorization Form - Community Plan
Last Published 04.23.2018
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Spiriva Respimat (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Steglujan (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Taltz (Michigan) Prior Authorization Form - Community Plan
Last Published 05.07.2018
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Tanzeum (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Tecfidera (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Tekturna (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Temovate (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Test Strips (Michigan) Prior Authorization Form - Community Plan
Last Published 07.26.2018
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Tobramycin Inhalation Solution (Tobi / Tobi Podhaler) (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Trelegy Ellipta (Michigan) Prior Authorization Form - Community Plan
Last Published 11.07.2019
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Tymlos (Michigan) Prior Authorization Form - Community Plan
Last Published 05.07.2018
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Uloric (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Valcyte (Michigan) Prior Authorization Form - Community Plan
Last Published 05.07.2018
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Vemlidy (Michigan) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Victoza (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Vyndamax / Vyndaqel (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Xarelto (Michigan) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Xeljanz (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Xenical (Michigan) Prior Authorization Form - Community Plan
Last Published 05.21.2018
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Xifaxan (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
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Xolair (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Xyrem (Michigan) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Zyvox (Michigan) Prior Authorization Form - Community Plan
Last Published 04.27.2018