Michigan Prior Authorization Request Form - For Prescription Drugs Instructions - FIS 2288

Sep 17, 2026

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Michigan Prior Authorization Request Form for Prescription Drugs provides instructions for prescribers to initiate prior authorization requests with a patient’s health plan using standard form FIS 2288. It explains legal requirements under PA 218 of 1956 (MCL 500.2212c), defines expedited versus standard timelines, and clarifies when approval is granted or considered void. The form also instructs submission rules, required certification for expedited review, and collects physician, patient, pharmacy, and medication details along with clinical rationale and contraindicated therapies.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Instructions

Legal basis and form purpose

Definitions and timelines (expedited vs standard)

Submission and expedited certification requirements

Form Sections

Reason for request

Patient demographics

Pharmacy insurance plan

Prescriber information

Pharmacy information (optional)

Requested prescription drug information

Rationale for prior authorization

Failed/contraindicated therapies

Other pertinent information

Attestation and physician signature

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 mostrecent 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 orthe 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 Fax: 800-424-7648 (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:

FAQs

What is a prior authorization request for prescription drugs under this form?

A prior authorization request is a request for pre-approval from an insurer for specified medications or quantities before they are dispensed.

How long does the insurer have to grant or deny an expedited versus standard request?

For an expedited request, the insurer must grant or deny, or request needed additional information, within 72 hours of submission. For a standard request, the timeframe is 15 days after submission.

When is a prior authorization request considered void?

A request is considered void if the prescriber fails to submit requested additional information within 5 days for an expedited original submission, or within 21 days for a standard original submission.

Sep 17, 2026

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