Pharmacy Prior Authorization Forms

Pharmacy Prior Authorization
If a medication isn’t on the Upper Peninsula Health Plan’s formulary or if there is a restriction on a certain medication, it will need a prior authorization.  Below are the prior authorization forms that should be filled out by your doctor and sent to the Upper Peninsula Health Plan for approval.

Request for Prior Authorization Form
(Print Only)

Request for Prior Authorization Form
(Fillable)

J-Code Prior-Authorization Form
(Print Only) Effective May 2016.

J-Code Prior-Authorization Form
(Fillable) Effective May 2016.

Michigan Prior Authorization Request Form


Diplomat Specialty Pharmacy Form


RSV Procedures for Providers

RSV Criteria Summary


Page Last Updated: 04/4/2017