Medication/Enteral Feed Prior Authorizations

Obtaining prior authorizations for medications or pre-certification for testing and or other services is an unfortunate part of our physician’s daily tasks. Although the process is painful and time consuming, given the practice pattern of modern day medicine in the US, one can somewhat understand the emergence of this degree of external practice “management.” Luckily, most insurance companies do provide a comparable and efficacious list of alternative medications; therefore, before launching on this tedious endeavor, review the companies’ formulary or preferred medication list first.

Click on the plans below to obtain information on the prior authorization (PA) process for each major plan

Medicaid Prior Authorization for Medications 1-877-309-9493

Links to “preferred med list” and fax forms, other instructions and info.

Since the fax PA process need 24 hrs for approval, you can tell your pt to go to the pharmacy the next day, and be sure to write on your prescription to let the pharmacist know to call Medicaid for pending PA number

Medicaid Enteral Formula Prior Authorization Program 1-866-211-1736.

For patients taking oral formula, be sure to have weight and height info on hand. 

Write the approval # on Rx; this will be active for refills x 6 months (once an approval # is given, it WILL stay active for 6 months, even if the patient does not get monthly refills on time).

Each can of the standard enteral formula usually carries 200-300 calories. 

NYS/DOH Prior Authorization Work Sheet (the worksheet is actually not necessary as long as you know the pt’s Medicaid #/DOB/ht/wt)

To speak to an operator with a question regarding a specific approval # call 1 800 342 3005.

Medicare Part D Medication

Links to plans/formularies/standard fax PA forms and other info, also consider checking a very comprehensive site www.fingertipformulary.com

Family Health Plus Plan: low income insurance for pts not qualifying for Medicaid.

This is not Medicaid, so the prior authorization process is mediated by the FHP insurance company.

NY-Presbyterian Community Plan call 1-800-390-7634 using ESI formulary – the approval process takes 24 hrs, and the company will let the patient/pharmacy know when it is done, so you can give the patient a Rx without a PA number.