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. 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 12/31/2025.)
Medicaid, CSHCS, Healthy Michigan Formulary (List of Covered Drugs) – Large Print (Last updated 12/31/2025.)
- Common Formulary Prior Authorization Criteria (Last updated 1/1/2026.)
- 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 12/31/2025.)
- Medicaid Secondary Formulary (List of Covered Drugs) – Large Print (Last updated XX/XX/XXXX.)
- Medicaid Secondary (Non-Part D) Prior Authorization Criteria
- Machine Readable Formulary (JSON)
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.
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.
Page Last Updated: 01/7/2026