Skip to content

Find a pharmacy

Fill your prescription at our convenient locations.

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.

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

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