Medicaid Formularies

The Upper Peninsula Health Plan’s (UPHP) formularies are lists of medications that are recommended for use. Note: Effective 6/1/2016, UPHP’s formulary is aligned with the MCO Common Formulary. 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: 08/28/2019