form Form

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 most recent 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 or the patient’s ability to regain maximum function.

FIS 2288 (11/15) Department of Insurance and Financial Services Page 1 of 2 Michigan Prior Authorization 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 □Initial Authorization Request □Renewal 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 □Blue Cross Blue Shield of Michigan □ HAP □_ □Total Health Care □Blue Care Network □ 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? ___

FIS 2288 (11/15) Department of Insurance and Financial Services Page 2 of 2 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 Dosing Schedule 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.

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: __ LOB: __ Approved: _ Denied: ___ Approved By: __ Denied By: __ Effective Date: _ Reason for Denial: ___ Additional Comments: _ 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: ____