NYRx, the Medicaid Pharmacy Program

Forms, Worksheets & References

Title
Title
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
Continuous Glucose Monitor (CGM) Prior Authorization Worksheet
esketamine (Spravato®) Prior Authorization Worksheet for Prescribers
Growth Hormones Prior Authorization Worksheet for Prescribers
lidocaine patch Prior Authorization Worksheet for Prescribers
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
Preferred Insulin Pump or Patch Prior Authorization Worksheet
Pubertal Suppressants/Hormone Replacement Therapy for Treatment of Gender Dysphoria Prior Authorization Worksheet for Prescribers
somatropin (Serostim®) Prior Authorization Worksheet for Prescribers
Standardized Fax Prior Authorization Form
Topical Compounds Prior Authorization Worksheet for Prescribers

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