Criteria and Forms

As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department must develop utilization controls, including prior approval, for specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs.

Forms

• Certificate of Medical Necessity for Continuation of External Insulin Management System Prior Authorization Form (pdf)
• Certificate of Medical Necessity for External Insulin Management System Prior Authorization Form  (pdf)
• Antipsychotic Medications for Long-Term Care Residents (pdf)
• Prior Authorization Request Form Erythropoietic Support Agents - Aranesp, Procrit, Epogen (pdf)
• Drug Prior Authorization Form (pdf)
• Atypical Antipsychotic Medications in Children < 8 years Prior Authorization Request Form (pdf)
• ADHD Medication Prior Authorization Request Form (pdf)
• Extended Spectrum Antibiotics (pdf)
• Four Prescription Policy (pdf)
• Long Acting Atypical Antipsychotics (pdf)
• Makena Prior Approval Request Form (pdf)
• Oncology Agents Prior Approval Request Form (pdf)
• Prior Authorization Request Form - Blood Factor (pdf)
  
• Prior Authorization Request Form - Direct-Acting Antivirals for Hepatitis C (pdf)
• Prior Authorization Request Form - Refill Too Soon (pdf) 
• Prior Authorization Request Form - Third Party Liability (TPL) (pdf)
• Synagis (pdf)

• Continuous Glucose Monitor (CGM) Prior Authorization Criteria (pdf)
  
• Direct-Acting Antivirals (DAA) for Hepatitis C Prior Authorization Criteria (pdf)
  
• Exondys 51 (eteplirsen) (pdf)
• Makena Prior Authorization Criteria (pdf) 
  
• Synagis (palivizumab) Prior Authorization Criteria (pdf)
  
• Synagis (palivizumab) Rounding Criteria (pdf)
  

Some drugs that previously required special prior approval forms no longer require them. If the drug is not listed above, please submit prior approval requests using the regular prior approval form.

To request prior authorization

By phone: 1-800-252-8942
By fax: 1-217-524-7264