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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

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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

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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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  • Calcitonin Gene-Related Peptide [CGRP] Inhibitors (Michigan) Prior Authorization Form - Community Plan

    Last Published 11.09.2020

    "Aimovig, Ajovy, Emgality, Ubrelvy",
  • Incretin Mimetics and Combinations (Michigan) Prior Authorization Form - Community Plan

    Last Published 11.09.2020

    "Adlyxin, Bydureon Bcise, Ozempic, Rybelsus, Xultophy, Soliqua, Trulicity",
  • Insulins (Michigan) Prior Authorization Form - Community Plan

    Last Published 11.09.2020

    "Toujeo Solostar, Humulin 70/30 Kwikpens, insulin aspart 70/30 pens, insulin aspart 70/30 vials, Novolin 70/30 vials, Basaglar, Tresiba Flextouch pens, Tresiba Flextouch vials, Admelog vials, Admelog Solostar, Afrezza, Fiasp pens and penfills, Fiasp vials, Humalog U-200 Kwikpens, insulin aspart cartridges, insulin aspart pens, insulin aspart vials, insulin lispro U-100 Kwikpens, insulin lispro U-100 vials, Humulin N Kwikpens ",
  • Medicaid Synagis Authorization Request Form - Community Plan

    Last Published 05.07.2021

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

    Last Published 04.12.2021

    "Arymo, Conzip, Dolophine, Duragesic, Embeda, Exalgo, fentanyl patch, hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, methadone, Methadose, Morphabond ER, morphine sulfate ER, MS Contin, Nucynta ER, oxycodone ER, oxymorphone ER, Oxycontin, tramadol ER, Xtampza ER, Zohydro ER, acetaminophen w/codeine, acetaminophen-caffeine-dihydrocodeine, Apadaz, Ascomp/Codeine, benzhydrocodone-acetaminophen, butalbital-acetaminophen-caffeine w/codeine, butalbital-aspirin-caffeine w/codeine, butorphanol nasal spray, codeine sulfate, Dilaudid, Endocet, Fioricet/Codeine, Fiorinal/Codeine,hydrocodone-acetaminophen, hydrocodone-ibuprofen, hydromorphone, levorphanol, Lorcet HD, Lorcet Plus, Lorcet, Lortab, meperidine, morphine, Nalocet, Norco, Nucynta, Opana, opium tincture, Oxaydo, oxycodone, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, oxymorphone, pentazocine w/naloxone, Percocet, Primlev, Roxicodone, tramadol, tramadol-acetaminophen, Tylenol w/Codeine, Ultracet, Ultram, Vicodin HP, Xodol, Belbuca, Butrans, buprenorphine patches",
  • Proton Pump Inhibitors (Michigan) Prior Authorization Form - Community Plan

    Last Published 11.09.2020

    "Aciphex, rabeprazole, Nexium 24HR OTC, Prilosec OTC, omeprazole OTC, Protonix, Aciphex sprinkle, rabeprazole sprinkle, Dexilant, Esomep-EZS kit, Nexium, esomeprazole, esomeprazole strontium, Prevacid, Prevacid 24 HR, lansoprazole, Prilosec susp packet, omeprazole ODT, Protonix susp packet, Zegerid, omeprazole/sodium, Zegerid susp pack, omeprazole/sodium susp pack, Zegerid OTC caps, omeprazole/sodium OTC ",