Common Formulary Prior Authorization Request Form.pdf

FIS_2288_501398_7.pdf
Preview of Common Formulary Prior Authorization Request Form
🔗 Source: michigan.gov
📊 Size: 161 KB
📄 Pages: 3 pages
⬇️ Downloads: 75

Summary

Michigan Prior Authorization Request Form for prescription drugs is required by Public Act 218 of 1956, with a standard form, FIS 2288, provided by the Department of Insurance and Financial Services to simplify information exchange between prescribers and health insurers. The form is for prescribers to initiate prior authorization requests, with definitions for "prescriber" and "prescription drug" as per the Public Health Code. Insurers must comply with timeframes for processing requests, and prescribers must submit additional information within specified timeframes. The form includes sections for patient demographics, prescriber information, pharmacy information, requested prescription drug information, rationale for prior authorization, failed/contraindicated therapies, and other pertinent information.

Description

Michigan Prior Authorization Request Form for prescription drugs is required by Public Act 218 of 1956, with a standard form, FIS 2288, provided by the...

Technical Information

  • File Format: PDF
  • File Size: 161 KB
  • Pages: 3
  • Language: EN
  • Total Downloads: 75
  • Last Updated: 16 hours ago

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