EmblemHealth Prior (Rx) Authorization Form

Updated June 02, 2022

An EmblemHealth prior authorization form is a document used when requesting medical coverage from an individual’s health plan, specifically for prescription drugs. This form may be filled out by the enrollee, the prescriber, or an individual requesting coverage on the enrollee’s behalf.

  • Fax: 1 (877) 300-9695
  • Email: clinicalpharmacy@emblemhealth.com
  • Mail: EmblemHealth, Attn: Clinical Pharmacy Department, 441 Ninth Avenue, New York, NY 10001
  • Phone: 1 (877) 362-5670

How to Write

Step 1 – Begin by specifying the prescriber’s name, speciality, and full address.

Step 2 – State any brand/generic medication, dosage, strength and manufacturer (if known) of the drug you are suggesting for formulary addition.

Step 3 – Specify any formulary agents that are available in the same therapeutic class or for the same indication.

Step 4 – Indicate the advantage of the recommended agent over the current formulary options.

Step 5 – Specify whether or not you are affiliated with this drug’s manufacturer. If yes, how?

Step 6 – Submit supporting literature citations with the request (a minimum of two documenting journal articles is requested).

Step 7 – The prescriber must supply their signature and the date at the bottom of the page.