Michigan Prior Authorization Request Form For Prescription Drugs Page 2

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FIS 2288 (9/15) Department of Insurance and Financial Services Page 1 of 2
Michigan Prior Authorization
Request Form for Prescription Drugs
□ Expedited Review Request: I hereby certify that a standard review period may seriously jeopardize
the life or health of the patient or the patient’s ability to regain maximum function.
Physician’s Direct Contact Phone Number (
) _____-_________
Initials: _________________
A) Reason for Request
□ Initial Authorization Request
□ Renewal Request
□ DAW
B) Patient Demographics
Is patient hospitalized: □ Yes □ No
Patient Name: ____________________________________________
DOB: ____________________
Patient Health Plan ID: _________________________________________________________________
□ Male
□ Female
C) Pharmacy Insurance Plan
□ Priority
□ Magellan
□ Blue Cross Blue Shield of Michigan
□ HAP
□ _________________
□ Total Health Care
□ Blue Care Network
□ HealthPlus of Michigan
□ Meridian Health Plan
D) Prescriber Information
Prescriber Name: ________________________ NPI: _________________ Specialty: ______________
DEA (required for controlled substance requests only): _____________________
Contact Name: __________________ Contact Phone: ______________ Contact Fax: _______________
Health Plan Provider ID (if accessible): ____________________________________________________
E) Pharmacy Information (optional)
Pharmacy Name____________________________ Pharmacy Telephone_________________________
F) Requested Prescription Drug Information
Drug Name: ______________________________________________ Strength: ________________
Dosing Schedule: _______________________ Duration: ____________________________________
Diagnosis (specific) with ICD#: _________________________________________________________
Place of infusion / injection (if applicable): _______________________________________________
Facility Provider ID / NPI: _____________________________________________________________
Has the patient already started the medication? _______ Yes _______No If so, when? ___________
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