Michigan Prior Authorization Request Form For Prescription Drugs Page 3

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FIS 2288 (9/15) Department of Insurance and Financial Services Page 2 of 2
G) Rationale for Prior Authorization (e.g., information such as history of present illness, past medical
history, current medications, etc.; you may also attach chart notes to support your request if you
believe they will assist with the review process)
H) Failed/Contraindicated Therapies
Drug Name
Strength
Dosing Schedule
Duration
Adverse Event/Specific Failure
__________
________
______________
_________
_________________________
__________
________
______________
_________
_________________________
__________
________
______________
_________
_________________________
I)
Other Pertinent Information (Optional - to be filled out if other information is necessary such as
relevant diagnostic labs, measures of response to treatment, etc.) Please refer to plan’s website for
additional information that may be necessary for review. Please note that sending this form with
insufficient clinical information may result in extended review period or adverse determination.
I represent to the best of my knowledge and belief that the information provided is true, complete and fully
disclosed. A person may be committing insurance fraud if false or deceptive information with the intent to
defraud is provided.
Physician’s Name: ____________________________________________________________
Physician’s Signature: _________________________________________________________
Date: ____________
PA 218 of 1956 as amended requires the use of a standard prior authorization form by prescribers when a patient's health plan
requires prior authorization for prescription drug benefits.
*For Health Plan Use Only*
Request Date: ______________________________
LOB: __________________________________
Approved: _________________________________
Denied: _______________________________
Approved By: ______________________________
Denied By:
______________________________
Effective Date: _____________________________
Reason for Denial: _______________________
Additional Comments: _________________________________________________________________
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