Forms and Applications
NEW! For Members: Michigan Drug Assistance Program Online Application Instructions
The drug assistance program is moving from paper applications to an online system. This is where you will find the instructions to complete your first online application for your next coverage period.
MIDAP Online Application Instructions for Members
In order to start your online application, go to milogin.michigan.gov.
- Create a MILogin account. (You will receive an email confirmation, verifying your access after you have created your account.) Guide for how to create a new MILogin account for members is available here.
- Login to MILogin and request access to the Michigan Drug Assistance Program (MIDAP).
- Complete the User Registration.
- Click “Initiate New Application” to complete begin your application.
- If you have a MIDAP ID number, use your MIDAP ID number when completing your online application.
For detailed instructions, please download the MIDAP member user guide here.
MIDAP Applications
- DCH-3926, MIDAP Application (MIDAP Application for members wanting to complete a paper application rather than the online application. It is used for first-time applicants and those who are renewing their membership).
- DCH-3926-AR, MIDAP Application (Arabic)
- DCH-3926-SP, MIDAP Application (Spanish)
Hepatitis C Forms
The Michigan Department of Health and Human Services—Michigan Drug Assistance Program (MIDAP) is pleased to announce that hepatitis treatment is now available for eligible individuals co-infected with HIV and Hepatitis C. Beginning March 1, 2018, MIDAP began providing treatment assistance for Hepatitis C medications, including Epclusa, Harvoni, Mavyret and Zepatier. For eligible individuals, the Hepatitis C treatment is provided at no cost.
The prior authorization form is initiated by the client’s physician. All questions on the prior authorization and patient consent form must be completed, signed and dated; required documents must be attached. Upon receipt, the forms are reviewed by MIDAP and a clinical review team.
MIDAP is the payer of last resort and will continue to provide Ryan White services to those who do not have medication coverage by public or private health insurance plans.
- MDHHS MIDAP Hep C PA Criteria Denial
- MDHHS MIDAP Hep C Prior Auth Form
- MDHHS MIDAP Hep C Patient Consent Form
Other Resources
- *New* MIDAP Marketplace Health Insurance Plans Matrix 2019 (guide to provide information on availability and estimated costs of 2019 Marketplace Health Insurance Plans for Wayne, Kent, and Ingham counties)
- MIDAP Drug Formulary
- MIDAP Premium Assistance Application Video
- MIDAP Qualifications
MIDAP Forms
- Request for Prior Authorization
- MDHHS-5422, Combined Declarations
- MDHHS-5422-SP, Combined Declarations (Spanish)
- MDHHS-5422-AR, Combined Declarations (Arabic)
- MDHHS-5429, 30 Day Medication Request
- MDHHS-5430, Change of Status
- MDHHS-5545, Michigan Drug Assistance Program (MIDAP) Grievance
For Case Managers
MIDAP Online Application Instructions
To assist a MIDAP member with a new application please go to milogintp.michigan.gov. You will need to register as a Case Manager through this MILogin Third Party website.
- For a guide on how to create a new MILogin account as a case manager please download the MILogin Guide here.
- For detailed instructions for the MIDAP online application please download the MIDAP user guide here.
- Access the video for case managers on how to assist clients for the online application here.
