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Michigan Prior Authorization Request Form For Prescription Drugs Instructions Important Please read all instructions below before completing FIS 2288. 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 lefthand corner. 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 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. FIS 2288 11/15 Department of Insurance and Financial Services Page 1 of 2 Request Form for Prescription Drugs SUBMIT THIS FORM TO THE PATIENT S HEALTH PLAN 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 Renewal Request Initial Authorization 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 Total Health Care Blue Cross Blue Shield of Michigan Blue Care Network HAP 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 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 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. 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 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. 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 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. FIS 2288 11/15 Department of Insurance and Financial Services Page 1 of 2 Request Form for Prescription Drugs SUBMIT THIS FORM TO THE PATIENT S HEALTH PLAN 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 Renewal Request Initial Authorization 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 Total Health Care Blue Cross Blue Shield of Michigan Blue Care Network HAP 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 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 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. 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. FIS 2288 11/15 Department of Insurance and Financial Services Page 1 of 2 Request Form for Prescription Drugs SUBMIT THIS FORM TO THE PATIENT S HEALTH PLAN 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 Renewal Request Initial Authorization 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 Total Health Care Blue Cross Blue Shield of Michigan Blue Care Network HAP 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 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 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. 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 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 Approved Denied Denied By Effective Date Reason for Denial Additional Comments.