NYRx, the Medicaid Pharmacy Program

Forms, Worksheets & References

Electronic PA Requests

Beginning Summer 2025, NYRx, the Medicaid Pharmacy Program, will accept electronic PA requests via CoverMyMeds®. For more information, reach out to NYRxEO@primetherapeutics.com.

Prior Authorization Forms, Worksheets & References

Title
NYRx, the Medicaid Pharmacy Program Prescription Prior Authorization Request Form (Standardized Prior Authorization Request Form)
Anabolic Steroids Prior Authorization Worksheet for Prescribers
Antiretroviral/Antiretroviral Drug/Drug Interactions Reference
Antiretrovirals (ARV) Prior Authorization Worksheet
Atypical Antipsychotics (AAP) Prior Authorization Worksheet
Central Nervous System (CNS) Stimulants Prior Authorization Worksheet for Prescribers
Growth Hormones Prior Authorization Worksheet for Prescribers
IMCIVREE® Prior Authorization Worksheet for Prescribers
lidocaine patch Prior Authorization Worksheet for Prescribers
NYRx, the Medicaid Pharmacy Program Continuous Glucose Monitor (CGM) Prior Authorization Request Form
NYRx, the Medicaid Pharmacy Program Preferred Insulin Pump or Patch Prior Authorization Request Form
NYRx, the Medicaid Pharmacy Program Spravato® (esketamine) Nasal Spray Prior Authorization Request Form
Opioid Agents Prior Authorization Worksheet for Prescribers
oxazolidinone antibiotics (Sivextro®, Zyvox®) Prior Authorization Worksheet for Prescribers
palivizumab (Synagis®) Prior Authorization Worksheet for Prescribers
Pharmacy Emergency Supply Worksheet
Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH Prior Authorization Worksheet for Prescribers
Pubertal Suppressants/Hormone Replacement Therapy for Treatment of Gender Dysphoria Prior Authorization Worksheet for Prescribers
somatropin (Serostim®) Prior Authorization Worksheet for Prescribers
Topical Compounds Prior Authorization Worksheet for Prescribers

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