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

Prescribers Web Prior Authorization User Guide

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).