NYS Medicaid Pharmacy Prior Authorization Programs

Forms, Worksheets & References

Title
Title
Standardized Fax Prior Authorization Form
Antiretroviral/Antiretroviral Drug/Drug Interactions Reference
Antiretroviral (ARV)/ Non-ARV Drug To Drug Interaction Reference
Hepatitis C Worksheet & Resources
Opioid Agents Prior Authorization Worksheet for Prescribers
Second Generation Antipsychotics (SGA) Prior Authorization (PA) Instructions
Anabolic Steroids Prior Authorization Worksheet for Prescribers
becaplermin gel (Regranex®) Prior Authorization Worksheet for Prescribers
lidocaine patch (Lidoderm®) Prior Authorization Worksheet for Prescribers
oxazolidinone antibiotics (Sivextro®, Zyvox®) Prior Authorization Worksheet for Prescribers
palivizumab (Synagis®) Prior Authorization Worksheet for Prescribers
Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH Prior Authorization Worksheet for Prescribers
Pharmacy Emergency Supply Worksheet

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