Search

print Print

New York Community Plan Pharmacy Prior Authorization Forms

To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:

CoverMyMeds logo

Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select Electronic Prior Authorization (ePA)
SureScripts logo

Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select Electronic prior authorization (ePA)

Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.

Upon selection, page will refresh

Contraceptive exception (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 12.30.2023

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

"Amethia, Amethyst, Ashlyna, Aurovela, balcoltra, Beyaz, Blisovi, Camrese Lo, Camrese, Charlotte, Daysee, Depo-Provera, Depo-SubQ Provera, Dolishale, drospirenone-ethinyl estradiol, drospirenone-ethinyl estradiol-levomefolate, Finzala, Gemmily, Hailey, Jaimiess, Jasmiel, Joyeaux, Junel, Kaitlib, Larin, Layolis, levonorgestrel-ethinyl estradiol, Lo Loestrin, Loestrin, Lo-Jaimiess, loryna, lo-zumandimine, Merzee, Mibelas, Microgestin, Minastrin, Natizia, Nextstellis, nikki, norethindrone-ethinyl estradiol, norgestimate-ethinyl estradiol, ocella, Ortho Tri-Cyclen Lo, Rivelsa, Safyral, Simpesse, syeda, Tarina, Taysofy, Taytulla, Tri-lo-estarylla, tri-lo-marzia, tri-lo-mili, tri-lo-sprintec, tri-vylibra lo, Tydemy, vestura, Wymzya FE, Yasmin, Yaz, zumandimine",

Erythromycin 0.5% Ophthalmic Ointment - Zero Dollar Cost Share (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Erythromycin Ophthalmic Ointment,

GLP-1 Agonists (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Adlyxin, Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza ,

Gonadotropin-Releasing Hormone Agonists (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

leuprolide acetate, Lupaneta Pack, Lupron Depot, Lupron Depot Ped, Triptodur,

Hepatitis C Medications (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,

Hepatitis C Medications (NY-CHIP) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: New York Child Health Plus

Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,

Humira (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Humira,

Inhaled Corticosteroids (NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan

Last Published 02.25.2022

Use this paper fax form to submit requests for the following state plans: New York Child Health Plus, Pennsylvania UnitedHealthcare Community Plan for Kids

Qvar RediHaler, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Alvesco, ArmonAir Digihaler ,

Raloxifene - Zero Dollar Cost Share (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Raloxifene ,

SGLT-2 Inhibitors (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Farxiga, Invokana, Invokamet, Invokamet XR, Jardiance, Steglatro, Segluromet, Synjardy, Synjardy XR, Xigduo XR,

Statins (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Altoprev, Crestor, rosuvastatin, Ezallor, Flolipid, simvastatin suspension, fluvastatin, Lescol XL, fluvastatin ER, Lipitor, atorvastatin, Livalo, lovastatin, Pravachol, pravastatin, Zocor, simvastatin, Zypitamag ,

Suboxone / Subutex (New York Essential Plan) Prior Authorization Form - Community Plan

Last Published 02.23.2022

Use this paper fax form to submit requests for the following state plans: New York Essential Plan

Suboxone, buprenorphine/naloxone, buprenorphine, Zubsolv, Bunavail ,

Suboxone / Subutex (NY-CHIP) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: New York Child Health Plus

Suboxone, buprenorphine, Zubsolv, Bunavail, buprenorphine-naloxone,