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NYS Medicaid Pharmacy Prior Authorization Programs

Providers • Prior Authorization • Forms and Worksheets

Prior Authorization Forms and Worksheets

Prior Authorization Form
Title
Title
Standardized Fax Prior Authorization Form
Prior Authorization Worksheets
Title
Title
Other Clinical Criteria for Prescribers
Prior Authorization Instructions for Prescribers
Hepatitis C Agents Prior Authorization Worksheet for Prescribers
Opioid Agents Prior Authorization Worksheet for Prescribers
Second Generation Antipsychotics (SGA) Prior Authorization (PA) Instructions
CDRP Prior Authorization Worksheets
Title
Title
becaplermin gel (Regranex®) Prior Authorization Worksheet for Prescribers
emtricitabine/tenofovir disoproxil fumarate (Truvada®) Prior Authorization Worksheet for Prescribers
fentanyl mucosal agents Prior Authorization Worksheet for Prescribers
lidocaine patch (Lidoderm®) Prior Authorization Worksheet for Prescribers
linezolid (Zyvox®) Prior Authorization Worksheet for Prescribers
palivizumab (Synagis®) Prior Authorization Worksheet for Prescribers
somatropin (Serostim®) Prior Authorization Worksheet for Prescribers
PDP Classes subject to CDRP
Title
Title
Anabolic Steroids Prior Authorization Worksheet for Prescribers
Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH Prior Authorization Worksheet for Prescribers
Prior Authorization Request Worksheet for Prescribers can be used for CNS Stimulants for 18 years and older
Topical Immunomodulators Prior Authorization Worksheet for Prescribers
Mandatory Generic Drug Program Prior Authorization Worksheets
Title
Title
Mandatory Generic Prescriber worksheet
Mandatory Generic Prescriber instructions
Emergency Supply
Title
Title
Pharmacy worksheet
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