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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.

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Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select Electronic Prior Authorization (ePA)
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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select Electronic prior authorization (ePA)

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

    Last Published 07.28.2023

    "fentanyl, Actiq, benzhydrocodone/acetaminophen, Apadaz, butorphanol, butalbital/acetaminophen/caffeine/codeine, Fioricet/codeine, Ascomp/codeine, butalbital/aspirin/caffeine/codeine, Demerol, meperidine, acetaminophen/caffeine/dihydrocodeine, Trezix, Dilaudid, Fentora, fentanyl, hydrocodone/ibuprofen, hydromorphone, levorphanol, Lortab, Nalocet, Nucynta, Roxicodone, Oxaydo, oxymorphone, pentazocine/naloxone, Percocet, Prolate, tramadol, Ultracet, Ultram, codeine, acetaminophen/codeine, Endocet, oxycodone/acetaminophen, hydrocodone/acetaminophen, Xodol, hydromorphone, morphine, oxycodone, tramadol, tramadol/acetaminophen, Seglentis, morphine ER, MS Contin, tramadol ER, Conzip, Belbuca, hydrocodone ER, Hysingla ER, hydrocodone ER, hydromorphone ER, methadone, Methadose, Nucynta ER, oxycodone ER, Oxycontin, oxymorphone ER, Xtampza ER, fentanyl patches, Butrans, buprenorphine patches",