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NYS Medicaid Pharmacy Programs

Topical Immunomodulators

Topical Immunomodulators

Prior Authorization Call Line: 1-877-309-9493
Prior Authorization Fax Line: 1-800-268-2990

Prior authorization for Topical Immunomodulators has been implemented to reinforce appropriate use and to ensure utilization consistent with approved indications. Requests for prior authorization of Topical Immunomodulators can be initiated by either prescribers or their authorized agents. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).

Prior authorization requirements:

  • Prescribers are required to respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug.
  • Five refills for Topical Immunomodulator prescriptions are allowed.