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.

Prescriber 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.









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).