Michigan Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Download the PDF version of the Michigan Medicaid prior authorization form and open it using either Adobe Acrobat or Microsoft Word.

Step 2 – Begin by entering the date at the top of the page.

Step 3 – Next, enter the patient’s name, member ID number, gender, date of birth, and phone number into the “Patient Information” section.

Step 4 – In the “Prescriber Information” section, enter your name, specialty, NPI number, office phone number, office fax number, and office contact person.

Step 5 – Beneath “Diagnosis and Medical Information” you must enter the medication type, strength and route of administration, frequency, patient’s height and weight, expected length of therapy, drug quantity, patient’s BMI and date calculated, patient’s blood pressure and when it was taken, patient’s diagnosis related to medication request, and patient’s drug allergies.

Step 6 – In the “Rationale for Prior Authorization” field, you will need to explain your reasons for requesting this prescription instead of employing a drug from the Preferred Drug List (PDL).

Step 7 – Next, if applicable, list the name, reason for failure, and date of failure of any authorized medications that have been tried as treatment of the relevant diagnosis.

Step 8 – Type the date at the bottom of the page and print your form. Then, handwrite your signature where indicated and fax your form to the appropriate directory.