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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",
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Incretin Mimetics and Combinations (Michigan) Prior Authorization Form - Community Plan
Last Published 11.09.2020
"Adlyxin, Bydureon Bcise, Ozempic, Rybelsus, Xultophy, Soliqua, Trulicity",
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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 ",
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Medicaid Synagis Authorization Request Form - Community Plan
Last Published 09.24.2020
Synagis,
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Opioid Products [Long-acting] (Michigan) Prior Authorization Form - Community Plan
Last Published 11.09.2020
"morphine ER, Conzip, tramadol ER, methadose, methadose SF, methadone, Dolophine, hydromorphone ER, Hysingla ER, Kadian, MS Contin, Nucynta ER, Oxycontin, oxycodone ER, oxymorphone ER non-crush resistant, tramadol ER biphasic, Arymo ER, Belbuca, Xtampza ER, Zohydro ER, hydrocodone ER ",
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Opioid Products [Short-acting] (Michigan) Prior Authorization Form - Community Plan
Last Published 11.09.2020
"hydromorphone, hydrocodone/APAP, oxycodone/APAP, Endocet, oxycodone IR, tramadol, codeine, codeine/APAP, morphine sulfate, butorphanol spray, Fioricet w/codeine, codeine/APAP/caffeine/butalbital, Fiorinal w/codeine, codeine/ASA/caffeine/butalbital, Demerol, meperidine, dihydrocodeine/APAP/caffeine, Dilaudid, hydrocodone/ibuprofen, hydromorphone, levorphanol, Norco, Lorcet and Lorcet HD, Lortab, Nalocet, Percocet, Primlev, Prolate, Nucynta, oxymorphone, Opana, Oxaydo, oxycodone/ASA, oxycodone, Roxicodone, pentazocine/naloxone, Ultracet, tramadol/APAP, Ultram, Actiq, Fentora, fentanyl citrate buccal tabs, Apadaz",
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Opioid Products [Transdermal] (Michigan) Prior Authorization Form - Community Plan
Last Published 11.09.2020
"fentanyl patches, Duragesic, Butrans, buprenorphine patches ",
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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 ",