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 MedImpact at 800-681-9578, fill it out, and submit it to MedImpact for a determination.

Below are drug-specific forms that will help prescribers and staff provide all of the information required to make a determination for specific drugs.

All forms on this page are for use by prescribers and their staff only.

Exception Forms

Drug-Specific Prior Authorization Forms

The forms are listed in alphabetical order by drug name. Scroll down to view the list or click a link to jump to a specific section.

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Z

Disclaimer

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 MedImpact’s online pricing tool. The pricing tool will not provide cost estimates for the product selection penalty or medications that require prior authorization.