Medicaid Formularies

Click on the appropriate formulary link below. If you would like to request a paper copy, contact UPHP Customer Service at 1-800-835-2556 (TTY: 711) and we will mail you a paper copy at no charge.
(note: clicking some links will take you away from the UPHP website).

Medicaid, Children’s Special Health Care Services (CSHCS), and Health Michigan Plan

Medicaid, CSHCS, Healthy Michigan Formulary (List of Covered Drugs) (Last updated 04/01/2026.)

Medicaid, CSHCS, Healthy Michigan Formulary (List of Covered Drugs) – Large Print (Last updated 04/01/2026.)

• Common Formulary Prior Authorization Criteria (Last updated 05/01/2026.)
• UPHP Formulary Exception Request Criteria
• Xifaxan – Formulary Exception Criteria
• Formulary Change History
• Machine Readable Formulary (JSON)
• Michigan Preferred Drug List (PDL)/Single PDL

UPHP Medicaid Secondary (Medicaid – Medicare Eligible Dual Coverage) Plan

• Medicaid Secondary Formulary (List of Covered Drugs) (Last updated 04/01/2026.)
• Medicaid Secondary Formulary (List of Covered Drugs) – Large Print (Last updated 04/01/2026.)
• Medicaid Secondary (Non-Part D) Prior Authorization Criteria  (Last updated 05/01/2026.)
• UPHP Formulary Exception Request Criteria
• Machine Readable Formulary (JSON)

If you do not see your drug on the Medicaid, CSHCS, Healthy Michigan Formulary (List of Covered Drugs), then it may be a carve-out drug.

Carve-out drugs are covered by the State of Michigan fee-for-service Medicaid program. These are not covered by UPHP. This means that the Michigan Department of Health and Human Services (MDHHS) Medicaid program pays for the drug. You will use your mihealth card to receive the drugs.

Separate coverage rules such as requiring prior authorization and quantity limits may apply. For carve-out drugs, pharmacies need to submit claims to the fee-for-service Medicaid program directly through Prime Therapeutics. The help desk numbers for these carve-out drugs are 1-877-681-7540 (Members) and 1-877-624-5204 (Pharmacies).

View the fee-for-service drug list here: https://mi.primetherapeutics.com/provider/drug-lookup/

1. Search by the drug name.
2. Results are shown in a table. Look at the column titled “HEALTH PLAN CARVEOUT’.
3. If YES, then the drug is considered a carve-out. The pharmacy will bill fee-for-service Medicaid.

Upper Peninsula Health Plan (UPHP) provides comprehensive, evidence based medication coverage aligned with the Michigan Medicaid Health Plan Common Formulary. Coverage is consistent with nationally recognized clinical criteria and guidelines. Certain drugs may require prior authorization or step therapy. Providers may utilize the prior authorization forms below to request approval of prior authorization or medical necessity reviews. Choose the appropriate formulary to obtain detailed coverage information.

• UPHP Medicaid Prescription Prior Authorization Request Form
• Michigan Medicaid (Fee for Service) Prior Authorization Request Form

If we make an initial coverage decision about your drug and you aren’t satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we made.

How to ask for an Appeal

• In writing using the appropriate form below:

UPHP Medicaid Prescription Appeal Request Form

Mail your request to:

Express Scripts
Attn: Clinical Appeals Department
P.O. Box 66588
St. Louis, MO 63166-6588
Fax your request to: 1-877-852-4070

• By Phone (available 24 hours a day, 7 days a week):

1-866-902-6743
(TTY: 1-800-716-3231)

You may use Accredo® Specialty Pharmacy  or any specialty pharmacy in our network. Click here to search all pharmacies in our network.

• Medicaid Prescription Drug Claim Form
• Pharmacy Resources for Claims Prior to 1/1/2026 (Prime Therapeutics): Pharmacy Network Information- MAC Appeals, Payer Sheet
• Pharmacy Resources for Claims Starting on or after 1/1/2026 (Express Scripts): Pharmacist Resource Center – Patient info, Claims, Appeals, and more.