[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283881-105":3,"doc-detail-283881-en":81,"detail-sidebar-cat-1-en-105":97},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","michigan-department-of-health-and-human-services-prescription-drug-prior-authorization-form-general-pa-form","Michigan Department of Health and Human Services - Prescription Drug Prior Authorization Form - General PA Form","","Prescription Drug Prior Authorization Form for Michigan Department of Health and Human Services captures complete beneficiary, prescriber, and pharmacy details required for submission. The form collects requested medication specifics, including drug name, strength, dosing, duration, and clinical justification for the exception request. It also records diagnosis, preferred medication feasibility, prior provider evaluation, previous therapies, and relevant tests or procedures with findings and dates. Submission instructions require faxing the completed form to Prime Therapeutics State Government Solutions without a fax cover sheet.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/michigan-department-of-health-and-human-services-prescription-drug-prior-authorization-form-general-pa-form/283881/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/michigan-department-of-health-and-human-services-prescription-drug-prior-authorization-form-general-pa-form/283881.png","ImageObject",442,249,{"name":42,"@type":43},"Mimi","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-31","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should the completed prior authorization form be faxed, and is a fax cover sheet required?","Question",{"text":63,"@type":64},"Fax the form to 888-603-7696, and a fax cover sheet is not required.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What happens if the form is incomplete or left blank after being returned once?",{"text":68,"@type":64},"Incomplete forms are returned only once for missing information; any issues remaining blank after that receive a denial and will not qualify for MDHHS physician review until completed or clearly marked ‘N/A’.",{"name":70,"@type":61,"acceptedAnswer":71},"What clinical information must be provided to support the exception request?",{"text":72,"@type":64},"Provide the diagnosis, answers to whether the beneficiary can use a preferred medication and whether other providers were seen, reasons for the exception request, previous medications tried with therapeutic failure reasons, and pertinent tests or procedures with findings and dates.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283881,1790185020,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":96,"read_time":26},2336477974920,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d",17,"Michigan Department of Health and Human Services Prescription Drug Prior Authorization Form General PA Form  \nFax this form to 888-603-7696. A fax cover sheet is not required.  \nAll information on this form must be addressed. Incomplete forms will be returned only once for missing information. Mark as ‘N/A’ if no information is available or does not apply. Issues that remain blank after being returned once will receive a denial and will not qualify for MDHHS physician review until completed or clearly marked ‘N/A’.  \nBENEFICIARY INFORMATION  \nBeneficiary’s Last Name:   Beneficiary’s First Name:    \nDate of Birth:   Sex:  Male  Female Medicaid ID:    \nPRESCRIBER INFORMATION  \nPrescriber’s Last Name:   Prescriber’s First Name:   Prescriber’s Credentials (Select One):  MD  PA  NP  DO  Other:  Specialty:   Prescriber’s NPI:   DEA:   DEA Expiration:    \nPrescriber’s Phone:   Prescriber’s Fax:    \nPERSON COMPLETING FORM  \n\n| Person’s Last Name:\u003Cbr>Person’s First Name:\u003Cbr>Person’s Title:\u003Cbr>Person’s Phone:   Form Completion Date:  \u003Cbr>PHARMACY INFORMATION |  |\n| --- | --- |\n|  |  |\n|  |  |\n|  | Person’s Fax:   Requested Start Date:   |\n\nPharmacy’s Name:   Pharmacy’s Phone:   Pharmacy’s Fax:    \nREQUESTED MEDICATION  \nDrug Name:  \nDrug Strength:  \nDrug Dosing:  \nDuration of Treatment:    \nCLINICAL INFORMATION  \nDiagnosis for use of this medication:    \n1. Can this beneficiary use a preferred medication?  \n Yes  No  \nIf “No”, give reason below:  \n2. Has this beneficiary seen any other provider for this condition?  \n Yes  No  \nIf “Yes”, what was the provider’s specialty and recommendation?  \nSpecialty:    \nRecommendation:    \n3. Reason for the exception request: previous history of a medical condition, allergies, lab / test results, and / or other pertinent medical information. Mark as ‘N/A’ if no information is available and cannot be provided.  \nPREVIOUS SERVICES/THERAPY  \nNames of previous medications tried for this condition: Please include the reasons for therapeutic failure. Mark as ‘N/A’ if no information is available and cannot be provided.  \nDrug Name:   Strength:   Directions:   Start Date:  End Date:   Reason for Failure:    \nDrug Name:   Strength:   Directions:   Start Date:  End Date:   Reason for Failure:    \nDrug Name:   Strength:   Directions:   Start Date:  End Date:   Reason for Failure:    \nTESTS OR PROCEDURES  \nPertinent laboratory test(s) or procedure(s) . Mark as ‘N/A’ if no information is available and cannot be provided.  \nProcedure:    \nFindings:   Date:    \nProcedure:    \nFindings:   Date:    \nProcedure:    \nFindings:   Date:    \nADDITIONAL COMMENTS  \nAdditional Comments:  \nSubmit requests to:  \nPrime Therapeutics State Government Solutions LLCAttn: GV – 4201  \nP.O. Box 64811  \nSt. Paul, MN 55164-0811  \nFax: 888-603-7696  \nPhone: 877-864-9014  \nThis form is available at [https://mi.primetherapeutics.com/provider/forms/](https://mi.primetherapeutics.com/provider/forms/) .","cbCaimVyMEs9n535","https://ap.wps.com/l/cbCaimVyMEs9n535","pdf",1879456,"English","# Beneficiary Information\n# Prescriber Information\n# Person Completing Form\n# Pharmacy Information\n# Requested Medication\n# Clinical Information\n# Previous Services/Therapy\n# Tests or Procedures\n# Additional Comments and Submission","[{\"question\":\"Where should the completed prior authorization form be faxed, and is a fax cover sheet required?\",\"answer\":\"Fax the form to 888-603-7696, and a fax cover sheet is not required.\"},{\"question\":\"What happens if the form is incomplete or left blank after being returned once?\",\"answer\":\"Incomplete forms are returned only once for missing information; any issues remaining blank after that receive a denial and will not qualify for MDHHS physician review until completed or clearly marked ‘N/A’.\"},{\"question\":\"What clinical information must be provided to support the exception request?\",\"answer\":\"Provide the diagnosis, answers to whether the beneficiary can use a preferred medication and whether other providers were seen, reasons for the exception request, previous medications tried with therapeutic failure reasons, and pertinent tests or procedures with findings and dates.\"}]","Michigan Department of Health and Human Services - Prescription Drug Prior Authorization Form - General PA Form | PDF",1789621359,{"code":4,"msg":82,"data":98},[99,104,109,114,119,124,127,132,137],{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},11,"Presentations",90,"presentations",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},12,"Resumes",80,"resumes",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},14,"Invoices",70,"invoices",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},15,"Posters",60,"posters",{"id":120,"doc_module":22,"doc_module_name":25,"category_name":121,"show_sort_weight":122,"slug":123},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":125,"slug":126},40,"forms",{"id":128,"doc_module":22,"doc_module_name":25,"category_name":129,"show_sort_weight":130,"slug":131},18,"Letters",30,"letters",{"id":133,"doc_module":22,"doc_module_name":25,"category_name":134,"show_sort_weight":135,"slug":136},21,"Paper Templates",5,"papers-templates",{"id":138,"doc_module":22,"doc_module_name":25,"category_name":139,"show_sort_weight":4,"slug":140},158,"General","general-158"]