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New York Medicaid Prior Authorization Form

New York Medicaid Prior Authorization Form

Updated July 27, 2023

A New York Medicaid prior authorization form is used when a medical practitioner needs to request Medicaid coverage for a drug that is not on the Preferred Drug List (PDL). In order for the request to be valid, the prescriber will need to present their medical justification(s) for not prescribing a preferred drug. Once completed, this form must be submitted via fax to the number provided below. A fillable PDF version is of the form is available on this page (compatible with Adobe Acrobat and Microsoft Word).

Fax – 1 (800) 268-2990

Phone – 1 (877) 309-9493

Preferred Drug List – Drugs deemed acceptable for prescription by the State