Nys Medicaid Prior Authorization Request Form For Prescriptions
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2Plan/PBM Name: _____________________ Plan/PBM Phone No. ________________ Plan/PBM Fax _______________
Plan Logo
website address:
NYS Medicaid Prior Authorization Request Form For Prescriptions
Rationale for Exception Request or Prior Authorization - All information must be complete and legible
Patient Information
First Name:
Last Name:
MI:
Male
Female
Date of Birth:
Member ID:
Is patient transitioning from a facility?
Yes
No
____/____/_____
If yes, provide name of facility: _________________________________________________
Provider Information
First Name:
Last Name:
Address:
NPI #:
Phone #:
Fax #:
Office Contact:
Specialty:
Medication/Medical and Dispensing Information
Medication:
Strength:
Frequency:
Qty:
Refill(s):
2
Case Specific Diagnosis/ICD9:
Route of Administration:
Oral
IM
SC
Transdermal
IV
Other
For physician administered, will this provider be ordering & administering?
Yes
No
If no, supply administering provider:
Please check one of the following:
This is a new medication and/or new health plan
This is continued therapy previously covered by the patient’s current health plan.
for the patient.
If checked, go to question 1
If checked, approx. date initiated _____/_____. Go to question 5
1. Does the drug require a dose titration of either multiple strengths and/or multiple doses per day?
Yes
No
If yes, provide titration schedule: _________________________________________________________
2. Is the drug being used for an FDA approved indication?
Yes
No
3
2.(a) If the answer to 2 is No, is its use supported by Official Compendia (AHFS DI®, DRUGDEX ®)
Yes
No
3. Has the patient experienced treatment failure with a preferred/formulary drug(s) or has the patient experienced
Yes
No
an adverse reaction with a preferred/formulary drug(s) in the therapeutic class? If yes, complete the following:
Drug and Dose
Route
Frequency
Approx. date range therapy
Outcome
began & stopped
_____/_____
_____/_____
_____/_____
_____/_____
4. Is there documented history of successful therapeutic control with a non-preferred/non-formulary drug and transition to a
preferred/formulary drug is medically contraindicated? If yes, explain:
Yes
No
5. Is this a change in dosage/day for the above medication?
Yes
No
6. Does the request require an expedited review?
Yes
No
7. Attach relevant lab results, tests and diagnostic studies performed that support use of therapy.
Check if attached
Required clinical information: Please provide all relevant clinical information in the box below to support a medical necessity
to determine coverage. Refer to health plan coverage requirements for the requested medication (see link above).
Please check here if documentation is attached.
I attest that this information is accurate and true, and that the supporting documentation is available for review upon request of said plan, the
NYSDOH or CMS. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a
Medicaid MC claim may be subject to civil penalties and treble damages under both federal and NYS False Claims Acts.
____/____/______
Prescriber’s Signature _________________________________________________________
Date
Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.
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Parent category: Medical