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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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  • Medicaid Synagis Authorization Request Form - Community Plan

    Last Published 11.22.2021

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

    Last Published 11.22.2021

    "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",