- 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
- *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
- 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