U-M Prescription Drug Plan Prior Authorization Request Forms

Information for Prescribers and their Staff Only

To comply with Section 2212c of Public Act 218 of 1956 in Michigan, which went into effect on July 1, 2016, the University of Michigan Prescription Drug Plan provides access to the standard prior authorization form for prescribers to initiate requests for prescriptions that require prior authorization from the plan.

For prescribers and staff only: View the Michigan Prior Authorization Request Form for Prescription Drugs

Prescribers and their staff may request the standard form by calling Magellen Rx at (888) 272-1346, fill it out, and submit it to Magellan Rx for a determination.

Recent changes to our formulary and coverage policies are available, along with drug-specific forms and criteria, to help prescribers and staff provide the information required to make a determination for specific drugs. 


Please be advised that the University of Michigan Prescription Drug Plan formulary is updated periodically and changes may appear prior to their effective date to allow for client notification. The University of Michigan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. Every effort is made to ensure complete and accurate information; however, the most accurate source of medication coverage and member cost is the Magellan Rx pricing tool. The pricing tool will not provide cost estimates for the product selection penalty or medications that require prior authorization.