Submit Prior Authorization

Prescribers

Please select Members or Prescribers to submit a prior authorization (PA), appeal, or exception request online using our online form.

 

Submit a prior authorization (PA), appeal, or exception request online by using our online form.

Web Prior Authorization User Guide

 

If you would like to check the status of your Prior Authorization with your authorization ID, please call 855-323-4580.

Member Web Prior Authorization

Patient Information

     As of April 1st, 2022, Michigan and Illinois Medicaid prior authorizations will be submitted via Cover My Meds



Prescriber Information






Diagnosis and Medical Information

     If requesting a compound, please enter for “Compound Bucket” and outline the ingredients in the additional information field.



Requestor Information





**If the requestor is not the Member or a Prescriber, attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent. We also accept copies of legal documents recognized by the state or other legal documentation showing authority). For more information on appointing a representative, you may contact your plan.

Optional: Attach Supporting Documentation

You must include all necessary clinical documentation, office notes, and all related laboratory results to ensure a complete PA review. (PDFs only).