https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized Form

NYRx, the Medicaid Pharmacy Program Prescription Prior Authorization Request Form Fax form to 1-800-268-2990 | Requests are responded to within 24 hours

NYRx Prescription Prior Authorization Request Form
Page 1 of 4 © 2014–2025 Prime Therapeutics State Government Solutions LLC, a Prime Therapeutics LLC company
Revision Date: 08/11/25 INSTRUCTIONS Preferred products, used in accordance with FDA labeling, may not require prior authorization (PA). For a preferred product, refer to the NYRx Preferred Drug List (PDL). Please fill out all sections completely and legibly. MEMBER INFORMATION Member Last Name:

Member First Name:

Member Medicaid ID (two letters, five numbers, one letter):

Date of Birth (MM/DD/YYYY):
Sex: Male
Female
X Height (in/cm): Weight (lb/kg):

Allergies:

Is the member transitioning from a facility? Yes
No If Yes, provide facility name:

PRESCRIBER INFORMATION Prescriber Last Name:

Prescriber First Name:

Prescriber NPI:
Specialty:

Prescriber Street Address:

City:
State:
Zip:

Prescriber Phone:
Prescriber Fax:

Prescriber’s Authorized Agent:

Note: An authorized agent is an employee of the prescriber who has access to the member’s medical records and is submitting this form on the prescriber’s behalf. PA requests submitted by third parties will not be accepted. MEDICATION AND DISPENSING INFORMATION Drug Name:
Drug Strength:

Drug Formulation:
Dosing Frequency:

Quantity:
Day Supply:

Print Reset

Member Last Name:
Date of Birth (MM/DD/YYYY): NYRx Prescription Prior Authorization Request Form Page 2 of 4 Route of Administration (select one): Oral/Sublingual Topical/Transdermal
Intramuscular Intravenous Subcutaneous Other:
For physician-administered medication, will this provider be ordering and administering? Yes No If No, list administering provider: Select one of the following: New medication therapy Renewal of medication therapy previously covered by NYRx Same dose and frequency Approximate date therapy initiated (MM/DD/YYYY): New strength or frequency Prior dosage or frequency:
Approximate date therapy initiated (MM/DD/YYYY): Continuation of therapy from other/previous insurer Prior dosage or frequency:
Approximate date therapy initiated (MM/DD/YYYY):
CLINICAL CRITERIA

1. What diagnosis is this being prescribed for? Diagnosis #1: ICD-10 Code: Diagnosis #2: ICD-10 Code:
2. Is the drug being used for an FDA-approved or official compendia (AHFS DI®, DRUGDEX®) indication? Yes No If No, provide supporting literature for off-label use:

Member Last Name:
Date of Birth (MM/DD/YYYY):

NYRx Prescription Prior Authorization Request Form
Page 3 of 4

3. Does the drug require a dose titration of either multiple strengths and/or multiple doses per day? Yes No If Yes, provide titration schedule:

4. If prescribing a non-preferred agent, are you willing to prescribe a preferred agent as shown on the NYRx Preferred Drug List (PDL)? Yes No If No, what is the clinical rationale for the member being unable to use a preferred agent in the same drug class?

5. Has the member experienced treatment failure or an adverse reaction/allergy with a preferred drug within the therapeutic class for this condition? Yes No If Yes, provide details of the treatment failure or adverse reaction:

   Medication/Therapy #1 Drug Name and Dosage:

   Approximate date therapy initiated (MM/DD/YYYY):

   Approximate date therapy discontinued (MM/DD/YYYY):

   Treatment Failure/Adverse Reaction/Allergy:

   Medication/Therapy #2 Drug Name and Dosage:

   Approximate date therapy initiated (MM/DD/YYYY):

   Approximate date therapy discontinued (MM/DD/YYYY):

   Treatment Failure/Adverse Reaction/Allergy:

6. Is there documented history of successful therapeutic control with a non-preferred drug, and is transition to a preferred drug medically contraindicated? Yes No If Yes, explain:

Member Last Name:
Date of Birth (MM/DD/YYYY):

NYRx Prescription Prior Authorization Request Form
Page 4 of 4

7. Are the relevant lab results, tests, and diagnostic studies that were performed to support the use of therapy attached?
   Yes No Submission of this form confirms the information is accurate and true, and that the supporting documentation is available for review upon request of the New York State Department of Health or the Centers for Medicare & Medicaid Services. The submitter understands that any person who knowingly makes or causes to be made a false record to statement that is material to a Medicaid claim may be subject to civil penalties and treble damages under both the federal and New York State False Claims Acts. Fax the completed form to the NYRx Clinical Call Center at 1-800-268-2990. To contact the NYRx Clinical Call Center, call 1-877-309-9493. For the NYRx Preferred Drug List (PDL), visit https://newyork.fhsc.com/providers/pdl.asp.