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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Aranesp / Epogen / Procrit Initial Review (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Aranesp / Epogen / Procrit Reauthorization Review (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Benznidazole (Michigan) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Carac, Efudex / Fluorouracil Cream (0.5%, 5%) (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cayston (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Claravis (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Clobetasol (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Compounds (Michigan) Prior Authorization Form - Community Plan
Last Modified 06.25.2018
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Daraprim (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Desmopressin / Stimate / DDAVP (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Dovonex (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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DPP-4 Inhibitors and Combination DPP-4 Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.01.2018
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Dronabinol / Marinol (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Elidel / Protopic (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Elmiron (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Endari (Michigan) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Enoxaparin (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Entresto (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Erleada (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.16.2018
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Fentanyl, Transdermal (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.19.2018
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Forteo (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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General Non-Preferred Medication (Michigan) Prior Authorization Form - Community Plan
Last Modified 06.22.2018
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Global Quantity Limits (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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GLP-1 Agonist (Michigan) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
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GLP-1 Agonist / Basal Insulin Combinations (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Gonadotropin-Releasing Hormone Agents [Lupron, Eligard, Trelstar, Lupaneta] (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
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Growth Hormone Medications, Re-Authorization Review (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Growth Hormones, Initial Review (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Hepatitis C Medications (MI, NY, WA) Prior Authorization Form - Community Plan
Last Modified 05.08.2018
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Humira (Michigan) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
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Humulin R U-500 (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Imitrex / Sumatriptan, Non-Oral (Michigan) Prior Authorization Form - Community Plan
Last Modified 07.26.2018
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Increlex (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Insulin Pen Needles and Syringes (Michigan) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Insulins (Michigan) Prior Authorization Form - Community Plan
Last Modified 02.07.2019
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Iron Chelators [Exjade, Ferriprox, Jadenu] (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.15.2018
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Lidocaine Patch (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lovaza (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Mefloquine / Lariam (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Mepron (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.04.2018
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Naprosyn / Naproxen Suspension (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Neupogen (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Ocaliva (Michigan) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Octreotide / Sandostatin (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Oncology Agents (Michigan) Prior Authorization Form - Community Plan
Last Modified 11.27.2018
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Oral Contraceptives (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Otezla (Michigan) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Praluent (Michigan) Prior Authorization Form - Community Plan
Last Modified 02.07.2019
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Protopic (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Pulmonary Arterial Hypertension (PAH) (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Pulmozyme (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Ranexa (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Rectiv (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Renvela (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Repatha (Michigan) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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Sensipar (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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SGLT-2 Inhibitors (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.16.2018
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Solaraze (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Soriatane (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Synagis Prior Authorization Form - Community Plan
Last Modified 11.20.2018
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Taltz (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Tanzeum (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Tecfidera (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Tekturna (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Temovate (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Test Strips (Michigan) Prior Authorization Form - Community Plan
Last Modified 07.26.2018
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Tobramycin Inhalation Solution (Tobi / Tobi Podhaler) (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Trelegy Ellipta (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.19.2018
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Tymlos (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Uloric (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Valcyte (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Vemlidy (Michigan) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Victoza (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Xarelto (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Xenical (Michigan) Prior Authorization Form - Community Plan
Last Modified 05.21.2018
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Xolair (Michigan) Prior Authorization Form - Community Plan
Last Modified 03.05.2019
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Zyvox (Michigan) Prior Authorization Form - Community Plan
Last Modified 04.27.2018