NYSDOH Implements Medicaid Prior Authorization Request Form for Prescriptions

Date Issued: 6/6/2013

NYSDOH Implements Medicaid Prior Authorization Request Form for Prescriptions

The New York State Department of Health (NYSDOH) has created a new user-friendly Medicaid Prior Authorization Request form to streamline managed care organizations' prior approval procedures for medications prescribed to members covered by Medicaid and Family Health Plus. EmblemHealth is complying with NYSDOH's requirement to use this form.

If the drug you want to prescribe for your EmblemHealth-covered Medicaid or Family Health Plus patient requires 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.