Medicaid Redesign Team Changes Effective July 8, 2013

Date Issued: 7/8/2013

New Medicaid Prior Authorization Request Form

By July 8, 2013, practitioners must use the new Medicaid Prior Authorization Request form to request prior approval for medications prescribed to members covered by Medicaid and Family Health Plus plans. New York State Department of Health (NYSDOH) developed the Prior Authorization Request form to streamline managed care organizations’ prior approval procedures. EmblemHealth is complying with NYSDOH’s requirement to use this form.

To obtain prior approval, please download and complete this form and fax it back to us at 1-877-300-9695.

The member may also download this form and present it to you for completion. Please fill out the form and fax it to the same number above.