New York Medicaid Prior Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Begin filling out the prior authorization form by entering the patient’s full name, gender, date of birth, member ID, and indicating whether the patient is transitioning from a facility.

Step 2 – Next, in the “Provider Information” section, you will need to provide your full name, address, NPI number, phone number, fax number, office contact name, and your specialty.

Step 3 – In the “Medication/Medical and Dispensing Information” section, you will need to enter the name, strength, prescription frequency, quantity, number of refills, relevant diagnosis, and route of administration for the drug in question.

Step 4 – Below that, you must use the checkboxes and appropriate field to indicate the following:

  • If this is a new medication and/or health plan for the patient
  • If this is a continued therapy
  • If the drug requires multiple strengths and/or doses per day
  • If the drug is being used for an FDA approved indication

Step 5 – Next, if the patient has tried other preferred drugs that failed in treatment, indicate that this is the case and provide the name, dosage, route, frequency, dates of therapy, and outcome for each applicable drug.

Step 6 – If there is a documented history of a non-preferred drug being successful in treatment of the relevant diagnosis where transition to a preferred drug is contraindicated, indicate that this is the case and write your explanation in the given field.

Step 7 – For item “5”, indicate whether this request is in regards to a change in dosage.

Step 8 – For item “6” indicate whether this request requires expedited review and enter your rationale.

Step 9 – You must include any relevant medical documentation that supports your request. If you will be attaching these documents to your fax, check the “Check if attached” and “Please check here if document is attached” checkboxes. Use the blank field in the “Required clinical information” box to write your justification and/or reference any supporting clinical/lab work or documentation.

Step 10 – Enter the date in the bottom right-hand corner of the document and print the form. Add your handwritten signature where indicated and fax the completed form along with any supporting medical documents to the appropriate directory.