Updated July 27, 2023
A Michigan Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug prescription in the state of Michigan. In this form, the physician provides their clinical reasoning for making this request instead of prescribing a drug from the Preferred Drug List (PDL). Supporting medical documentation and clinical documentation for the request should also be included. Once completed, this form must be faxed to the correct directory.
Preferred Drug List – List of pre-approved drugs by the State