Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
-
Actemra, Subcutaneous (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Albenza (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Alinia (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Benznidazole (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
-
Calcitonin Gene-Related Peptide [CGRP] (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Carac, Efudex / Fluorouracil Cream (0.5%, 5%) (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
-
Cayston (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
-
Cimzia (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Desmopressin / Stimate / DDAVP (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2018
-
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Dry Eye Disease (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Duexis & Vimovo (Michigan) Prior Authorization Form - Community Plan
Last Published 11.19.2019
-
Elmiron (Michigan) Prior Authorization Form - Community Plan
Last Published 04.20.2020
-
Enbrel (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Endari (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Erleada (Michigan) Prior Authorization Form - Community Plan
Last Published 10.16.2018
-
Erythropoiesis Stimulating Agents [Aranesp, Epogen, Procrit, Retacrit] (Michigan) Prior Authorization Form - Community Plan
Last Published 01.30.2020
-
Fentanyl Immediate-Release (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Fentanyl, Transdermal (Michigan) Prior Authorization Form - Community Plan
Last Published 10.19.2018
-
Firazyr (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Forteo (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
-
General Non-Preferred Medication (Michigan) Prior Authorization Form - Community Plan
Last Published 07.01.2020
-
Global Quantity Limits (Michigan) Prior Authorization Form - Community Plan
Last Published 04.30.2018
-
GLP-1 Agonist (Michigan) Prior Authorization Form - Community Plan
Last Published 01.08.2020
-
Gonadotropin-Releasing Hormone Agents [Lupron, Eligard, Trelstar, Lupaneta] (Michigan) Prior Authorization Form - Community Plan
Last Published 10.01.2018
-
Granulocyte Colony-Stimulating Factor, G-CSF (Michigan) Prior Authorization Form - Community Plan
Last Published 10.29.2019
-
Growth Hormone Medications, Re-Authorization Review (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2020
-
Growth Hormones, Initial Review (Michigan) Prior Authorization Form - Community Plan
Last Published 05.02.2018
-
Humira (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Imitrex / Sumatriptan, Non-Oral (Michigan) Prior Authorization Form - Community Plan
Last Published 07.26.2018
-
Increlex (Michigan) Prior Authorization Form - Community Plan
Last Published 04.29.2020
-
Insulin Pen Needles and Syringes (Michigan) Prior Authorization Form - Community Plan
Last Published 02.06.2019
-
Insulins (Michigan) Prior Authorization Form - Community Plan
Last Published 03.25.2019
-
Iron Chelators [Exjade, Ferriprox, Jadenu] (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Isotretinoin (Michigan) Prior Authorization Form - Community Plan
Last Published 01.14.2020
-
Krintafel (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Lidocaine Patch (Michigan) Prior Authorization Form - Community Plan
Last Published 01.14.2020
-
Lorbrena (Michigan) Prior Authorization Form - Community Plan
Last Published 03.26.2019
-
Lucemyra (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Medicaid Synagis Authorization Request - Community Plan
Last Published 11.22.2019
-
Motegrity (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
MS Agents [Multiple Sclerosis] (Michigan) Prior Authorization Form - Community Plan
Last Published 04.01.2019
-
Nuzyra (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Ocaliva (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
-
Olumiant (Michigan) Prior Authorization Form - Community Plan
Last Published 09.19.2019
-
Oncology Agents (Michigan) Prior Authorization Form - Community Plan
Last Published 11.27.2018
-
Orencia, Subcutaneous (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Orilissa (Michigan) Prior Authorization Form - Community Plan
Last Published 03.25.2019
-
Osphena (Michigan) Prior Authorization Form - Community Plan
Last Published 10.07.2019
-
Otezla (Michigan) Prior Authorization Form - Community Plan
Last Published 12.27.2018
-
Praluent (Michigan) Prior Authorization Form - Community Plan
Last Published 02.07.2019
-
Pulmonary Arterial Hypertension (PAH) (Michigan) Prior Authorization Form - Community Plan
Last Published 09.19.2019
-
Rayos (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Repatha (Michigan) Prior Authorization Form - Community Plan
Last Published 01.30.2019
-
SGLT-2 Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Published 10.16.2018
-
Short-Acting Opioid Products (Michigan) Prior Authorization Form - Community Plan
Last Published 10.15.2019
-
Siliq (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Spiriva Respimat (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Steglujan (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Test Strips (Michigan) Prior Authorization Form - Community Plan
Last Published 07.26.2018
-
Trelegy Ellipta (Michigan) Prior Authorization Form - Community Plan
Last Published 11.07.2019
-
Vemlidy (Michigan) Prior Authorization Form - Community Plan
Last Published 10.10.2018
-
Vyndamax / Vyndaqel (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Xeljanz (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Xifaxan (Michigan) Prior Authorization Form - Community Plan
Last Published 01.09.2020
-
Xolair (Michigan) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Xyrem (Michigan) Prior Authorization Form - Community Plan
Last Published 04.16.2019