Fee-for-Service Medicaid Prior Authorization Guidelines

This page provides Fee-for-Services (FFS) Medicaid and Children's Special Health Care Services guidelines and documentation requirements for submission of Prior Authorization (PA) requests when PA is required for selected physician-administered drugs, surgeries, procedures, services, medical supplies and equipment. Criteria will be updated, and new guidelines added as they become available.

For the most current requirements, please refer to this page rather than downloading each guideline page.

All PA requests should be submitted electronically, via CHAMPS. For questions regarding FFS Prior Authorization, call the Program Review Division at 1-800-622-0276. If CHAMPS is inaccessible, requests may be faxed to 517-335-0075.

• Exon Skipping Drugs for Duchenne Muscular Dystrophy
• Zynteglo
• Elevidys

For requests for or questions regarding PACERs, Negative Pressure Wound Therapy, Home Uterine Monitoring and Infusion Therapy, call 844-PACERMI (844-722-3764).