Michigan Prior Authorization Request

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MICHIGAN
Department Of Community Health Pharmacy Program
Prior Authorization Request
ADD/ADHD Therapy For Recipients Over Age 17 Years
All information addressed on this form must be provided for consideration of approval. Incomplete requests will not
be considered for approval and will be returned. Completed requests may be resubmitted at any time.
Prescribing Physician:
Beneficiary:
[ ] Male [ ] Female
Name: ____________________________________
Name: ________________________________________
First
Last
First
Last
(Please circle one: MD, PA, NP, DO, DDS, Other __________)
-
-
Phone #:
Medicaid #:
-
-
-
-
Fax #:
Date of Birth:
NPI:
Specialty: Psychiatry [ ] Psychology [ ] Social Worker [ ] Counselor [ ] Other [ ] _________________
Person completing form: __________________________________________ Rqstd start date: ____________
Name
Title
Date
-
-
Pharmacy: ___________________________________ Phone #:
Drug Name
Strength
Dosing
Duration of Tx
Diagnosis
MDCH asks that all requests have a current MAPS report included in the patient’s medical record at the
prescribing physician’s office. Do not include the report with this fax form. Has the prescribing physician
named above verified medication usage by obtaining and reviewing a MAPS report?
Yes
No.
[  Health Systems & Health Profession Licensing  Michigan Automated Prescription System.]
MDCH does not cover newly diagnosed adult ADHD without the diagnosis being confirmed by a mental
health professional (psychiatrist, clinical psychologist, clinical social worker or licensed/certified
counselor). If the prescribing physician named above is not a mental health professional (as described
above), but the beneficiary has been evaluated by one of these specialists confirming the diagnosis, please
document the provider’s full name, specialty and date of evaluation.
____________________________________________________________________________________________________
If the beneficiary has NOT been seen by one of these specialists, please document the full name of the
provider who confirmed the diagnosis along with the provider’s specialty and date of consult. Please
include copies of testing used and chart notes detailing signs & symptoms of the diagnosis as exhibited by
_________________________________________________
this recipient. _____________________________
Date of initial diagnosis _____________________
Date ADD/ADHD last treated _____________________
Names of previous medications tried for this condition:
Drug Name / Strength / Directions:
Date(s):
Reason for Failure:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What are the social implications of the diagnosis for this recipient? _________________________________
___________________________________________________________________________________________
Submit requests to:
Magellan Medicaid Administration
11013 W Broad Street Suite 500, Glen Allen, VA 23060
Fax: 888-603-7696 Phone: 877-864-9014
 Providers  Forms
This form is available at
Revised 3-29-2014

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