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Michigan PRIOR AUTHORIZATION REQUEST FORM Please complete this entire form and fax it to: 8669407328. If you have questions, please call 8003106826. This form contains multiple pages. Please complete
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Anyone who is required to provide information related to prior authorization for UnitedHealthcare Community Plan (UHCCP) pharmacy services may need to fill out the 'Who is?' form. This includes healthcare providers, pharmacies, or individuals seeking prior authorization for certain medications or therapies covered by UHCCP.
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This is the prior authorization form for pharmacy services by UnitedHealthcare.
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Healthcare providers and facilities offering pharmacy services are required to file this form.
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The form must be completed with patient information, prescriber details, medication details, and justification for the prior authorization request.
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