NYRx, the Medicaid Pharmacy Program

Forms, Worksheets & References

Title
Title
Anabolic Steroids Prior Authorization Worksheet for Prescribers
Antiretroviral/Antiretroviral Drug/Drug Interactions Reference
Antiretroviral (ARV)/ Non-ARV Drug To Drug Interaction Reference
Continuous Glucose Monitor (CGM) Prior Authorization Worksheet
esketamine (Spravato®) Prior Authorization Worksheet for Prescribers
Growth Hormone - Adults (18 Years and Older) Prior Authorization Worksheet for Prescribers
Hepatitis C Worksheet
lidocaine patch Prior Authorization Worksheet for Prescribers
Omnipod Prior Authorization Worksheet
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/Cross-Sex Hormones 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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