Pharmacy Prior Authorization

Pharmacy Prior Authorization

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

Access to Medical Pharmacy Portal

Medical Pharmacy Portal Step-by-Step Guide

Diplomat Specialty Pharmacy Form

Michigan Prior Authorization Request Form


Page Last Updated: 07/20/2018