How to Submit Prior Authorization Requests - Medication Authorization Request Form (MARF) for Soliris and Eculizumab (Michigan Commercial)

Sep 17, 2026

Guidance for Michigan and non-Michigan prescribers on submitting prior authorization requests for medical benefit drugs for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. Provides electronic submission steps through the Availity provider portal, and an alternative fax process using the Medication Authorization Request Form (MARF) when portal access is unavailable or for providers outside Michigan. Includes details on the Medical and Pharmacy Drug PA Portal training resources, plus MARF instructions and patient/physician fields for Soliris (eculizumab) and related eculizumab products.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Prior authorization request submission steps

Michigan prescribers (electronic submission)

Michigan prescribers (MARF fax option)

Non-Michigan prescribers (online steps and MARF fax option)

Medication Authorization Request Form (MARF) overview

Product coverage scope and fax instructions

Patient information and physician information

Step 1: disease state information

How to submit prior authorization requests for medical benefit drugs For Blue Cross commercial and BCN commercial Revised October 2025 Follow these steps to submit prior authorization requests when prescribing most drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. Note: The information below doesn’t apply to oncology medical benefit drugs. Michigan prescribers To submit prior authorization requests electronically: 1. Log in to our provider portal ([availity.com](availity.com)*) . 2. Click Payer Spaces on the menu bar and click the BCBSM and BCN logo. 3. Click the Medical and Pharmacy Benefit Drug Prior Auth tile on the Applications tab. 4. In the Medical and Pharmacy Drug PA Portal, click the Authorization menu and select Add New. 5. Enter the member’s last name, date of birth, subscriber ID and authorization start date. 6. Click Search and then select the appropriate member in the member list. 7. Complete all required fields and submit the request. If you’re registered for Availity Essentials ™ but aren’t able to access it, submit the prior authorization request using the Medication Authorization Request Form, or MARF, that’s on the next page. Fax it to the number on the form. Non-Michigan prescribers When submitting prior authorization requests, prescribers located outside of Michigan should complete the appropriate steps on the Getting Started page on [authorizations.bcbsm.com](authorizations.bcbsm.com. Look)[. Look](authorizations.bcbsm.com. Look) in the Submit prior authorization requests section. If a non-Michigan prescriber is unable to submit a prior authorization request using the instructions on the webpage, submit the request using the Medication Authorization Request Form, or MARF, that’s on the next page. Fax it to the number on the form. Information about the Medical and Pharmacy Drug PA Portal To learn how to use the Medical and Pharmacy Drug PA Portal, view a recorded demo by going to Blue Cross and BCN’s Provider Training site, searching on drugs and launching the Medical and Pharmacy Drug Prior Auth portal overview mini module. For detailed information about accessing the Provider Training site, see the “Online training” section of the Training Tools page on [authorizations.bcbsm.com](authorizations.bcbsm.com). *Clicking this link means that you’re leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we’re not responsible for its content. Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services. | Blue Cross Blue Shield/Blue Care Network of Michigan
Medication Authorization Request Form
Soliris® (eculizumab) : J1300, BkemvTM (eculizumab-aeeb): Q5139, Epysqli® (eculizumab-aagh):
Q5151 | | | | --- | --- | --- | | This form is to be used by participating physicians to obtain coverage for Soliris. For commercial members only, please complete this form and submit via fax to 1-877-325-5979. If you have any questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. | | | | PATIENT INFORMATION | PHYSICIAN INFORMATION | | | Name | Name | | | ID Number | Specialty | | | D.O. B. Male Female | Address | | | Diagnosis | City /State/Zip | | | Drug Name | Phone/Fax: P: ( ) - F: ( ) - | | | Dose and Quantity | NPI | | | Directions | Contact Person | | | Date of Service(s) | Contact Person Phone / Ext. | | | STEP 1: DISEASE STATE INFORMATION | | | 1. Is this request for: Initiation Continuation Date patient started therapy: 2. Site of administration? Provider office/Home infusion Other: Hospital outpatient facility (go to \#3) Reason for Hospital Outpatient administration: 3. Please specify location of admi

FAQs

How do Michigan prescribers submit prior authorization requests electronically?

Log in to the provider portal, choose Payer Spaces, open the BCBSM and BCN logo, select the Medical and Pharmacy Benefit Drug Prior Auth tile, then use Authorization > Add New to enter member details, complete required fields, and submit the request.

What if a prescriber cannot access Availity Essentials?

Submit the prior authorization request using the Medication Authorization Request Form (MARF) on the next page, and fax it to the number listed on the form.

How do non-Michigan prescribers submit prior authorization requests?

Complete the appropriate steps on the Getting Started page in the Submit prior authorization requests section. If unable to submit using the webpage instructions, submit using the MARF and fax it to the number on the form.

Sep 17, 2026

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