Pharmacy benefit authorization requests

To ensure authorization requests are accurate and complete, and to streamline workflows for providers and our internal teams, follow the submission steps below.

First, review pharmacy benefit coverage and criteria
Submit your pharmacy benefit authorization requests to the Pharmacy Department through one of the methods below

For Medicare plans

Submit Medicare drug authorization requests through the following:

Electronic prior authorization (ePA)
Fax: Send your completed forms to 877.974.4411
Phone: Call 800.466.6642

Forms:

For Medicaid and Healthy Michigan Plans

Submit Medicaid and Healthy Michigan Plan drug authorization requests through the following:

Electronic prior authorization (ePA)
Fax: Send your completed fax forms to 877.974.4411

Forms

Medicaid pharmacy form

For Employer Group and MyPriority plans

Submit Employer Group and MyPriority drug authorization requests through the following:

Electronic prior authorization (ePA)
Fax: Send your completed fax forms to 877.974.4411

Forms: