Autthorization michigan 2025

1. Click ‘Get Form’ to open the Michigan Prior Authorization Request Form in the editor.
2. Begin by selecting either 'Standard Review Request' or 'Expedited Review Request' based on your patient's needs. If choosing expedited, ensure you certify that a standard review may jeopardize the patient's health.
3. Fill in the 'Patient Demographics' section, including the patient's name, date of birth, and health plan ID. Indicate if the patient is hospitalized.
4. In the 'Pharmacy Insurance Plan' section, select the appropriate insurance provider from the list provided.
5. Complete the 'Prescriber Information' section with your details, including your NPI and DEA number if applicable.
6. Provide information about the requested prescription drug in section F, including drug name, strength, dosing schedule, and diagnosis with ICD#.
7. Use sections G and H to provide rationale for prior authorization and any failed therapies. Include any additional pertinent information as needed.
8. Finally, sign and date the form at the bottom before submitting it directly to the patient’s health plan.

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