Try for free

NY Medicaid Enteral Formula PA Prescriber Worksheet

New York Medicaid prescribers use this worksheet to prepare an enteral formula prior authorization before entering it on the Enteral Prior Authorization portal or the phone-based interactive voice response system. It is not submitted anywhere. The automated system asks the same questions, issues an 11-digit prior authorization number, and the prescriber records that number on the member's order or prescription.

Who completes it

An enrolled New York Medicaid prescriber (physician, physician assistant, resident, nurse practitioner or midwife) answers the questions and enters them in the portal or IVR. Dispensers may not start an enteral formula prior authorization.

Submitting and payment

How to submit it
Enter the request yourself on the Enteral PA portal or by IVR, then keep the worksheet and supporting documentation in the member's medical record; do not send the worksheet as a prior approval request.
Who pays
The authorization covers enteral formula codes B4149 to B4162 under the benefit limit in 18 NYCRR 505.5(g)(3), with up to five refills per authorization.

Good to know

  • The automated system allows up to 2,500 calories a day for tube-fed members or those with an inborn metabolic disorder, and 1,250 calories a day for orally fed members with BMI under 18.5.
  • Manual prior approval is needed for orally fed members with BMI over 18.5, anyone needing more than the allowed calories, or members with a permanent structural limitation.
  • Request generally equivalent products with the same HCPCS code under one authorization with combined calories; products that are not equivalent need separate authorizations.
  • Some products are covered by WIC, but Medicaid authorizations can be obtained before WIC enrollment.

Get the official form

Download the current version from the source each time; forms change without notice.

New York State Medicaid Program - Enteral Formula Prior Authorization Prescriber Worksheet

Official pagePDF

Get the note ready with Vero

New York State Department of Health, Office of Health Insurance Programs (eMedNY) takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

See how Vero Scribe works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can request an enteral formula prior authorization from New York Medicaid?

Only an enrolled New York Medicaid prescriber: a physician, physician assistant, resident, nurse practitioner or midwife. The pharmacy or supplier cannot initiate it. The prescriber enters it on the Enteral PA portal or IVR, and caller ID is recorded for audit, so it should not be blocked.

What questions apply to orally fed members?

Whether a condition prevents eating normal, mashed or pureed foods; whether dietary alternatives such as instant breakfast drinks or rice cereal failed; whether an adult lost over 5 percent of weight in two months or a child gained none in six months; and whether objective medical evidence supports enteral nutrition. Answers must match the medical record.