Fillable Michigan Prior Authorization Request Form For Prescription Drugs

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Michigan Prior Authorization Request Form For Prescription Drugs

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Michigan Prior Authorization Request Form
For Prescription Drugs Instructions
Important: Please read all instructions below before completing FIS 2288.
Section 2212c of Public Act 218 of 1956, MCL 500.2212c, requires the use of a standard prior authorization form
when a policy, certificate or contract requires prior authorization for prescription drug benefits.
A standard form, FIS 2288, is being made available by the Department of Insurance and Financial Services to
simplify exchanges of information between prescribers and health insurers as part of the process of requesting
prescription drug prior authorization. This form will be updated periodically and the form number and most
recent revision date are displayed in the top left-hand corner.
This form is made available for use by prescribers to initiate a prior authorization request with the
health insurer.
Prior authorization requests are defined as requests for pre-approval from an insurer for specified
medications or quantities of medications before they are dispensed.
“Prescriber” means the term as defined in section 17708 of the Public Health Code, 1978 PA 368, MCL
333.17708.
“Prescription drug” means the term as defined in section 17708 of the Public Health Code, 1978 PA 368,
MCL 333.17708.
Pursuant to MCL 500.2212c, prescribers and insurers must comply with required timeframes pertaining
to the processing of a prior authorization request. Insurers may request additional information or
clarification needed to process a prior authorization request.
The prior authorization is considered granted if the insurer fails to grant the request, deny the request, or
require additional information of the prescriber within 72 hours after the date and time of submission of
an expedited prior authorization request or within 15 days after the date and time of submission of a
standard prior authorization request. If additional information is requested by an insurer, a prior
authorization request is considered to have been granted by the insurer if the insurer fails to grant the
request, deny the request, or otherwise respond to the request of the prescriber within 72 hours after the
date and time of submission of the additional information for an expedited prior authorization request; or
within 15 days after the date and time of submission of the additional information for standard prior
authorization request.
The prior authorization is considered void if the prescriber fails to submit the additional information
within 5 days after the date and time of the original submission of a properly completed expedited prior
authorization request or within 21 days after the date and time of the original submission of a properly
completed standard prior authorization request.
In order to designate a prior authorization request for expedited review, a prescriber must certify that
applying the 15-day standard review period may seriously jeopardize the life and health of the patient or
the patient’s ability to regain maximum function.
PRESCRIBERS PLEASE SUBMIT THIS FORM TO THE PATIENT’S HEALTH PLAN ONLY. Please
do not send to the department.
Only provide the physician’s direct contact number and initials if you are requesting an Expedited Review
Request.
FIS 2288 (10/16) Department of Insurance and Financial Services Page 1 of 2
Michigan Prior Authorization
Request Form for Prescription Drugs
(PRESCRIBERS SUBMIT THIS FORM TO THE PATIENT’S HEALTH PLAN)
□
Standard Review Request
□
Expedited Review Request: I hereby certify that a standard review period may seriously
jeopardize the life or health of the patient or the patient’s ability to regain maximum function.
Physician’s Direct Contact Phone Number ( ) _____-_________ Initials: _________________
A) Reason for Request
□ Initial Authorization Request □ Renewal Request □ DAW
B) Patient Demographics
Is patient hospitalized:
□ Yes □ No
Patient Name: ____________________________________________ DOB: ____________________
Patient Health Plan ID: _________________________________________________________________
□ Male □ Female
C) Pharmacy Insurance Plan
□ Priority □ Magellan □ Blue Cross Blue Shield of Michigan □ HAP □ _________________
□ Total Health Care □ Blue Care Network □ HealthPlus of Michigan □ Meridian Health Plan
D) Prescriber Information
Prescriber Name: ________________________ NPI: _________________ Specialty: ______________
DEA (required for controlled substance requests only): _____________________
Contact Name: __________________ Contact Phone: ______________ Contact Fax: _______________
Health Plan Provider ID (if accessible): ____________________________________________________
E) Pharmacy Information (optional)
Pharmacy Name____________________________ Pharmacy Telephone_________________________
F) Requested Prescription Drug Information
Drug Name: _____________________________________________________ Strength: __________
Dosing Schedule: __________________________________________ Duration: _________________
Diagnosis (specific) with ICD#: __________________________________________________________
Place of infusion / injection (if applicable): _________________________________________________
Facility Provider ID / NPI: ______________________________________________________________
Has the patient already started the medication? _______ Yes _______No If so, when? ___________
FIS 2288 (10/16) Department of Insurance and Financial Services Page 2 of 2
G) Rationale for Prior Authorization (e.g., information such as history of present illness, past medical
history, current medications, etc.; you may also attach chart notes to support your request if you
believe they will assist with the review process)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
H) Failed/Contraindicated Therapies
Drug Name Strength Dosing Schedule Duration Adverse Event/Specific Failure
__________ ________ ______________ _________ _________________________
__________ ________ ______________ _________ _________________________
__________ ________ ______________ _________ _________________________
I) Other Pertinent Information (Optional - to be filled out if other information is necessary such as
relevant diagnostic labs, measures of response to treatment, etc.) Please refer to plan’s website for
additional information that may be necessary for review. Please note that sending this form with
insufficient clinical information may result in extended review period or adverse determination.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PA 218 of 1956 as amended requires the use of a standard prior authorization form by prescribers when a patient's health plan
requires prior authorization for prescription drug benefits.
*For Health Plan Use Only*
Request Date: ______________________________ LOB: __________________________________
Approved: _________________________________ Denied: _______________________________
Approved By: ______________________________ Denied By:
______________________________
Effective Date: _____________________________ Reason for Denial: _______________________
Additional Comments: _________________________________________________________________
I represent to the best of my knowledge and belief that the information provided is true, complete and fully
disclosed. A person may be committing insurance fraud if false or deceptive information with the intent to
defraud is provided.
Physician’s Name: ____________________________________________________________
Physician’s Signature: _________________________________________________________
Date: ____________
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Michigan Prior Authorization Request Form For Prescription Drugs

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Completed 4 February 2021

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