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

ADHD Products (HI, NJ, NY-CHIP, PA-CHIP, RI) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion

"Brand Adderall, generic amphetamine/dextroamphetamine, Brand Adderall XR, generic amphetamine/dextroamphetamine ER, Brand Intuniv, generic guanfacine ER, Brand Metadate ER, generic methylphenidate ER tab, generic methylphenidate ER (CD), Brand Concerta, generic methylphenidate ER OSM, Brand Ritalin, generic methylphenidate, generic methylphenidate ER (LA), Brand Ritalin LA, Brand Strattera, generic atomoxetine, Brand Vyvanse, Adhansia XR, Brand Adzenys XR-ODT, Brand Adzenys ER, generic amphetamine ER susp, Brand Aptensio XR, generic methylphenidate ER cap, Brand Cotempla XR-ODT, Brand Daytrana, Brand Desoxyn, generic methamphetamine, Brand Dexedrine, generic dextroamphetamine ER, Brand Dyanavel XR, Brand Evekeo, Evekeo ODT, generic amphetamine, Brand Focalin, generic dexmethylphenidate, Brand Focalin XR, generic dexmethylphenidate ER, Jornay PM, Brand Kapvay, generic clonidine ER, Brand Methylin, generic methylphenidate soln, Brand Mydayis, Brand Procentra, generic dextroamphetamine soln, Brand Quillichew ER, Brand Quillivant XR, Brand Zenzedi, generic dextroamphetamine, generic Relexxii, generic methylphenidate ER (OSM), Qelbree, Azstarys, generic methylphenidate patch ",

ADHD Products (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

Adderall XR, Adderall, Adhansia XR, Adzenys ER, Adzenys XR-ODT, amphetamine ER, amphetamine, amphetamine/dextroamphetamine ER, amphetamine/dextroamphetamine, Aptensio XR, atomoxetine, clonidine ER, Concerta, Cotempla XR-ODT, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate ER, dexmethylphenidate, dextroamphetamine ER, dextroamphetamine, Dyanavel XR, Evekeo ODT, Evekeo, Focalin XR, Focalin, guanfacine ER, Intuniv, Jornay PM, Kapvay, Metadate ER, methamphetamine, Methylin, methylphenidate ER, methylphenidate, Mydayis, Procentra, Quillichew ER, Quillivant XR, Relexxii, Ritalin LA, Ritalin, Strattera, Vyvanse, Zenzedi,

Antipsychotics (NJ, NY-CHIP, NY-EPP, PA-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 Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, Pennsylvania UnitedHealthcare Community Plan for Kids

"Abilify Maintena, Abilify MyCite, Abilify, aripiprazole ODT, aripiprazole, Aristada, asenapine, Caplyta, chlorpromazine, clozapine, clozapine ODT, Clozaril, Fanapt, Fazaclo, fluphenazine, Geodon, Haldol, haloperidol decanoate, haloperidol, Invega, Invega Sustenna, Invega Trinza, Invega Hafyera, Latuda, loxapine, Lybalvi, molindone, olanzapine, olanzapine ODT, paliperidone, perphenazine, Perseris, pimozide, quetiapine, quetiapine ER, Rexulti, Risperdal Consta, Risperdal, risperidone ODT, risperidone, Saphris, Secuado, Seroquel, Seroquel XR, thioridazine, thiothixene, trifluoperazine, Versacloz, Vraylar, ziprasidone, Zyprexa, Zyprexa Zydis",

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",

Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion

Dupixent,

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 (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, Pennsylvania UnitedHealthcare Community Plan for Kids

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

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 ,

Medicaid Synagis Authorization Request Form - Community Plan

Last Published 04.01.2023

Please complete this entire form for UnitedHealthcare Community Plan members needing a Synagis prescription and fax it to the UnitedHealthcare Community Plan Prior Authorization Department. Excludes: New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me

Synagis,

Opioid Products (NJ, NY-CHIP, NY-EPP, PA-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 Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, Pennsylvania UnitedHealthcare Community Plan for Kids

Morphine ER, Duragesic, Fentanyl transdermal, Zohydro ER, Hydrocodone ER, Oxymorphone ER, Hydromorphone ER, Hysingla ER, MS Contin, Nucynta ER, Oxycontin, Oxycodone CR, Xtampza ER, Methadose, Methadone, Conzip, Tramadol ER Butorphanol, Carisoprodol-aspirin-codeine, Codeine, Acetaminophen-codeine, Butalbital-acetaminophen-caffeine-codeine, Fioricet/codeine, Ascomp/codeine, Butalbital-aspirin-caffeine-codeine, Morphine, Hydrocodone-acetaminophen, Lortab, Xodol, Hydrocodone-ibuprofen, Dilaudid, Hydromorphone, Oxycodone, Roxicodone, Oxaydo, Oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, Oxycodone-aspirin, Oxymorphone, Pentazocine-naloxone, Ultram, Synapryn, Tramadol, Qdolo, Ultracet, Tramadol-acetaminophen, Nucynta, Meperidine, Levorphanol, Acetaminophen-caffeine-dihydrocodeine, Trezix, Belladonna alkaloids-opium, opium, Apadaz, Benzhydrocodone-acetaminophen ,

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,

SGLT-2 Inhibitors (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan

Last Published 04.01.2023

Use this paper fax form to submit requests for the following state plans: Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, Pennsylvania UnitedHealthcare Community Plan for Kids

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