New York Medicaid members, including those in managed care plans, get their pharmacy benefit through NYRx, and this standardized form is how a prescriber requests prior authorization by fax for a non-preferred drug or one subject to clinical criteria. It applies unless the drug has its own NYRx form or worksheet. Fax requests are answered within 24 hours by fax back to the prescriber.
The prescriber or the prescriber's authorized agent completes all four pages. An authorized agent is an employee with access to the member's medical records, such as a nurse or medical assistant; requests from third parties are not accepted, and pharmacies cannot obtain the authorization.
Page 1 notes that preferred products used in accordance with FDA labeling may not need prior authorization, and points to the NYRx Preferred Drug List. Fill out every section completely and legibly. Before using this form, check whether the drug has its own NYRx request form or worksheet, such as those for CNS stimulants, opioids or growth hormone, since the standardized form is for drugs without one.
Enter the member's last and first name and the Medicaid ID in its printed format of two letters, five numbers and one letter. Add date of birth as MM/DD/YYYY, sex (Male, Female or X), height, weight and allergies. Answer whether the member is transitioning from a facility, and if yes, name the facility. The member's last name and date of birth repeat at the top of pages 2 to 4.
Give the prescriber's name, NPI, specialty, street address, phone and fax. The fax number matters because NYRx sends its decision back to it. If an authorized agent submits, enter the agent's name; the form defines an authorized agent as an employee of the prescriber who has access to the member's medical records, and it rejects requests submitted by third parties.
List drug name, strength, formulation, dosing frequency, quantity and day supply, then select the route of administration. For physician-administered medication, say whether this provider will order and administer it, or name the administering provider. Choose new therapy, renewal of therapy previously covered by NYRx (same dose, or a new strength or frequency with the prior dose), or continuation from another insurer, with approximate start dates.
Question 1 asks for up to two diagnoses with ICD-10 codes. Question 2 asks whether the drug is used for an FDA-approved or official compendia indication (AHFS DI or DRUGDEX); if not, attach supporting literature for the off-label use. Question 3 asks whether the drug needs dose titration across multiple strengths or doses per day, and if so, for the titration schedule.
Question 4 applies to non-preferred agents: state whether you are willing to prescribe a preferred agent from the Preferred Drug List and, if not, the clinical reason the member cannot use one in the same class. Question 5 records treatment failure, adverse reaction or allergy with a preferred drug, with space for two prior therapies, their dosage, start and stop dates, and what happened.
Question 6 asks whether there is a documented history of successful therapeutic control with the non-preferred drug and whether transition to a preferred drug is medically contraindicated, with space to explain. Question 7 asks whether relevant lab results, tests and diagnostic studies supporting the therapy are attached. These answers carry the case for non-preferred drugs, which need treatment failure, adverse reaction or documented stable control.
Page 4 states that submitting the form confirms the information is accurate and true and that supporting documentation is available for review on request of the New York State Department of Health or CMS. It warns of civil penalties and treble damages under the federal and New York False Claims Acts for false material records. Fax the completed form to the NYRx Clinical Call Center.
Download the current version from the source each time; forms change without notice.
NYRx, the Medicaid Pharmacy Program Prescription Prior Authorization Request Form
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.
Sources for this guide
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Only a prescriber with an active NPI who is enrolled in NYRx, or that prescriber's authorized agent. An authorized agent is an employee of the prescriber with access to the member's medical records, such as a nurse or medical assistant. Pharmacies cannot obtain prior authorization, although they can start a CoverMyMeds request for the prescriber to complete.
Fax requests are responded to within 24 hours, by fax back to the number on the form. Most phone requests are decided during the call, and CoverMyMeds requests can be approved in real time or are answered within 24 hours. Sending a second request for the same member and drug within 24 hours slows processing.
Yes. Pharmacy benefits were carved out of New York Medicaid managed care into NYRx in April 2023, so prescription prior authorization for both fee-for-service and managed care members goes to NYRx on this form, a drug-specific NYRx form, by phone or through CoverMyMeds.
In most cases, preferred products prescribed according to FDA labeling do not require prior authorization. Check the NYRx Preferred Drug List, where red superscripts mark clinical criteria for a drug or class, or the Preferred Drug Quick List, and consider a preferred product before submitting.