Medicaid Formularies

The retail prescription benefit is an important component of our member’s comprehensive treatment program. The goal of the Upper Peninsula Health Plan (UPHP) is to provide our members rational, clinically appropriate, and cost effective pharmaceutical care.

The UPHP Medicaid-CSHCS-Healthy Michigan formularies are aligned with the MDHHS (Michigan Department of Health and Human Services) Common Formulary for all contracted health plans in the State of Michigan per the Comprehensive Health Plan contract. An MCO Common Formulary Workgroup of representatives from contracted health plans provides recommendations to MDHHS on drugs to be included on the MDHHS Common Formulary. MDHHS has final approval authority for MDHHS Common Formulary coverage. UPHP’s formulary cannot be more restrictive than the coverage parameters of the MDHHS Common Formulary, but may be less restrictive in some instances.

For further information, click here.

Click on the appropriate formulary link below and key in the first few letters of the drug name
(note: clicking these links will take you away from the UPHP website).

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.

Prescription Prior Authorization Form/Medicaid

Diplomat Specialty Pharmacy Form

Michigan Prior Authorization Request Form


Page Last Updated: 10/11/2019