Forms and Links
Pharmacy Authorizations
- Prescription Prior Authorization/Medicaid
- UPHP Advantage and Choice Part D Coverage Determination Request Form
- UPHP MI Health Link Part D Coverage Determination Request Form
- Diplomat Specialty Pharmacy
- Medical Pharmacy Prior Authorized HCPCS Codes
- Magellan Rx Medical Pharmacy Portal
- Michigan Prior Authorization Request Form
Medical Authorizations
DME Authorizations
Other Forms
- Personal Care Supplement Request for Reimbursement
- Appointment of Representative Form
- Care-Coordination/Case-Management Referral Form
- Delivery Notification Form
- Notification of Pregnant Member
- Healthy Michigan Plan Health Risk Assessment
- Information Update Form
- Medical Needs Form – Fax completed form to UPHP
- Price Negotiation Request Form
- Release of Protected Health Information Form
Page Last Updated: 01/31/2019