Pharmacy Services

Specialty Medication Prior Authorization Criteria: Medicaid, CHP, and Metal-Level Plans (PDF)

Specialty Medication Prior Authorization Criteria: Medicare (PDF)

Prescription Medication Prior Authorization Request Form (PDF)

Opioid Prior Authorization Form (PDF)

Hepatitis C Prior Authorization Form (PDF)

Medicare Medication Prior Authorization Request Form (PDF)

Electronic Drug Coverage Determination Form

New York State Department of Health standardized prior authorization form (PDF)

Child Health Plus (CHP), HealthierLife (HARP), and Medicaid Managed Care

2018 Formulary (PDF)

Quick reference list (PDF)

Metal-Level Products

2018 Formulary (PDF)

2017 Formulary (PDF)

Essential Plan

2018 Formulary (PDF)

2017 Formulary (PDF)

Metal-Level Products and Essential Plans Formulary Changes: Effective January 1, 2018 (PDF)

Fully Integrated Duals Advantage (FIDA), (Medicare-Medicaid Plan [MMP]) Formulary

2017 Formulary (PDF)

Medicaid, Child Health Plus, and Healthier Life Formulary Changes for April/May 2018 (PDF)

Notice on the 2018 Flu Season Medications (PDF)

Medicaid, Child Health Plus, and Healthier Life Formulary Changes for January 2018 (PDF)

Qualified Health Plans and Essential Plans Formulary Changes for 2018 (PDF)

Child Health Plus (CHP), HealthierLife (HARP), and Medicaid Managed Care Formulary Changes (2017) (PDF)

Medicare Advantage Flex Plan and Medicare Advantage $0 Premium Formulary Changes (2017) (PDF)

Medicare Dual Advantage, Medicaid Advantage Plus and Dual Advantage Flex Formulary Changes (2017) (PDF)

Fully Integrated Duals Advantage Formulary Changes (2017) (PDF)

Metal-Level Products Formulary Changes (2017) (PDF)

Billing Medicaid Pharmacy LTC/SNF Claims (PDF)

Update on HealthierLife (HARP) Coverage and the Behavioral Health Benefit Carve-in: 9/6/2017 (PDF)

Notice on the 2017-2018 RSV season (PDF)

CVS Caremark Specialty Pharmacy Fax Enrollment Form (PDF)