Michigan law, MCL 500.2212c, requires a standard form whenever a health plan makes prescription drug benefits subject to prior authorization, and DIFS publishes FIS 2288 for that purpose. Prescribers use it to ask the patient's plan to pre-approve a drug, or a quantity of a drug, before it is dispensed. The plan must grant, deny or ask for more information within set deadlines, or the request is considered granted.
The prescriber completes the two-page request (pages 2 and 3 of the PDF), Sections A through I, and signs the attestation at the end; page 1 holds the instructions. The box marked For Health Plan Use Only is left for the insurer to record its decision.
Check one box at the top of page 1 of the request. Standard review gives the plan 15 days to respond. Expedited review gives it 72 hours, but checking that box is a certification that a standard review period may seriously jeopardize the patient's life or health or ability to regain maximum function. For expedited requests only, fill in the physician's direct contact phone number and initials so the plan can reach the prescriber quickly.
In Section A, mark whether this is an initial authorization request, a renewal request or a DAW (dispense as written) request. Section B asks whether the patient is currently hospitalized, then for the patient's name, date of birth, health plan ID number and sex. The plan matches the request to the member record using the name, date of birth and ID, so copy them exactly as they appear on the insurance card.
Section C names the patient's pharmacy insurance plan. Section D takes the prescriber's name, NPI and specialty, a DEA number (required only for controlled substance requests), an office contact name, phone and fax, and the health plan provider ID if you have it. Section E, the dispensing pharmacy's name and phone number, is optional. The contact details in Section D are where the plan will send questions or its decision.
Enter the drug name, strength, dosing schedule and duration, and a specific diagnosis with its ICD code. If the drug is infused or injected, give the place of infusion or injection and the facility's provider ID or NPI. Finish by answering whether the patient has already started the medication and, if so, when. The diagnosis line asks for a specific diagnosis, so avoid a general category or a symptom alone.
This is the clinical case for the request. The form suggests the history of present illness, past medical history and current medications, and you may attach chart notes if they will help the reviewer. Write enough for a reviewer to see why this drug, strength or quantity is needed for this patient; the form warns that insufficient clinical information may extend the review or lead to a denial.
List each drug already tried or ruled out, with its strength, dosing schedule, duration and the adverse event or specific failure. The table has three rows. Its columns ask how long each alternative was used and what went wrong, so give those details rather than only naming the drug, and note any contraindication that ruled an alternative out.
Section I is optional: add relevant diagnostic labs, measures of response to treatment or other details, and check the plan's website for anything else it needs for review. Below the plan-use box, the physician prints their name, signs and dates an attestation that the information is true, complete and fully disclosed. The form notes that providing false or deceptive information with intent to defraud may be insurance fraud.
Download the current version from the source each time; forms change without notice.
Michigan Prior Authorization Request Form for Prescription Drugs
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Within 72 hours of submission for an expedited request and 15 days for a standard request, the insurer must grant it, deny it or ask for more information. If it does none of these, the request is considered granted. The same 72-hour and 15-day clocks restart when the prescriber submits any additional information the insurer asked for.
Only when you can certify that applying the 15-day standard review period may seriously jeopardize the patient's life or health or the patient's ability to regain maximum function. Check Expedited Review Request at the top of the form and give the physician's direct contact phone number and initials, which the instructions reserve for expedited requests.
No. The instructions say to submit the form to the patient's health plan only and not to the department. Send it to the plan or the pharmacy benefit manager that handles its drug benefit. The form also points prescribers to the plan's website for any additional information the plan needs for review.
Yes. Section G, the rationale for prior authorization, says you may attach chart notes if they will help the review, and Section I has room for relevant labs or measures of response to treatment. The form warns that sending it with insufficient clinical information may lead to an extended review period or an adverse determination.