Drug authorizations

Drug authorization forms

For authorization forms and more drug-specific information, click the drug name below.

Use the right form for the member’s Priority Health plan:

Traditional: Most employer group plan members
Optimized: MyPriority individual plans and some employer group plans (member ID card will show Optimized RX: Yes)
Medicaid: Medicaid and Healthy Michigan plan members
Medicare: Medicare Advantage plan members and employer-sponsored Medicare plans such as MPSERS

Fax completed forms to Priority Health at 877.974.4411.

General drug request forms

Use these general forms when there is no drug-specific form listed.

General non-Medicare forms

Non-Covered Medication (01/2018)

Medical Drug Request (11/2018)

Quantity Limit Exception request form (09/2017)

Dispense as Written (DAW) (05/2018)

Michigan PA Request Form for Prescription Drugs (11/2015)

General Medicare forms

Medicare Part B Prior Authorization Form (05/2018)

Medicare Part D Coverage Determination Request Form (12/2011)

Medicare prescription drug request for redetermination (appeal) form (11/2011)

Hospice/Part D drug prior authorization form (05/2018)

Find drug-specific coverage, authorization and billing information

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