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New Medicaid Prior Authorization Request Form for Prescriptions

Date Issued: 1/17/2014

New Medicaid Prior Authorization Request Form for Prescriptions

For members covered by Medicaid or Family Health Plus, the New York State Department of Health has created a prior authorization form for drugs ordered for you by your doctor. Also known as prior approval, this form can be used by any member covered by Medicaid and Family Health Plus, but it must be filled out by your doctor.

  • Members: If your drug store tells you that the drug your doctor ordered needs prior approval from EmblemHealth, all you have to do is download, print and bring this form to your doctor. Your doctor will fill it out and send it to EmblemHealth to get consent for your medicine. Then you will be able to go back to the pharmacy and fill the prescription.
  • Doctors: If the drug you want to order for your EmblemHealth member calls for prior approval, please download and fill out this form and fax it back to us at 1-877-300-9695.

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