Medication Request Forms for Prior Authorization

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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 HAP Empowered Medicaid requests, please FAX the following form to (313) 664-5460.

• Request for Prior Authorization Form - Medicaid

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

• Medical Infusible Medication Request Form