Medication Request Forms for Prior Authorization

These documents require Adobe Reader.

Participating physicians and providers requesting authorization for medications can complete the appropriate form below and FAX to (313) 664-8045.

• Michigan Prior Authorization Request Form for Prescription Drugs
• Prescription determination request form for Medicare Part D

For Medical Infusible Medication requests, FAX to (313) 664-5338.

• Medical Infusible Medication Request Form