Michigan Prior Authorization Request Form For Prescription Drugs

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Michigan Prior Authorization Request Form
For Prescription Drugs
Instructions
Important: Please read all instructions below before completing FIS 2288.
Section 2212c of Public Act 218 of 1956, MCL 500.2212c, requires the use of a standard prior
authorization form when a policy, certificate or contract requires prior authorization for
prescription drug benefits.
A standard form, FIS 2288, is being made available to simplify exchanges of information
between prescribers and health insurers as part of the process of requesting prescription drug
prior authorization. This form will be updated periodically and the form number and most recent
revision date are displayed in the top left hand corner.
 Prior authorization requests are defined as requests for pre-approval from an insurer for
specified medications or quantities of medications before they are dispensed.
 Prescriber means the term as defined in section 17708 of the Public Health Code, 1978
PA 368, MCL 333.17708.
 Prescription drug means the term as defined in section 17708 of the Public Health Code,
1978 PA 368, MCL 333.17708.
 This form is made available for use by prescribers to initiate a prior authorization request.
 Insurers may request additional information or clarification needed to process a prior
authorization request. The prior authorization is not considered granted if the prescriber
fails to submit the additional information within 72 hours after the date and time of the
original submission of a properly completed prior authorization request.
 In order to designate a prior authorization request for expedited review, a prescriber must
certify that applying the 15-day standard review period may seriously jeopardize the life
and health of the patient or the patient’s ability to regain maximum function.
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