Pharmacy Prior Authorization

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.

Medical Pharmacy Program
Upper Peninsula Health Plan (UPHP) is committed to providing your patients, our members, with access to high-quality health care services that are consistent with nationally recognized clinical criteria and guidelines.
As part of that commitment, UPHP is collaborating with Magellan Rx Management, a specialty pharmaceutical management company to administer the Prior Authorizations of our Medical Pharmacy Program. Magellan Rx will conduct medical necessity and appropriateness reviews for specific medical billing medications.

List of Medical Pharmacy Program HCPCS codes that will be subject to Prior Authorization, effective October 1, 2017

Medical Pharmacy FAQs

The Quick Start Guide is a step-by-step instructions to help ordering physicians and their staff obtain prior authorization for the medical pharmacy program

Medical Pharmacy Bulletin

Training Webinar Registration

Request for Prescription Prior Authorization Form/Medicaid
(Print Only)

Request for Prescription Prior Authorization Form/Medicaid
(Fillable)

J-Code Prior-Authorization Form
(Print Only) Effective May 2016-September 30, 2017.

J-Code Prior-Authorization Form
(Fillable) Effective May 2016-September 30, 2017.

Michigan Prior Authorization Request Form


Diplomat Specialty Pharmacy Form


RSV Procedures for Providers

RSV Criteria Summary


Page Last Updated: 08/15/2017