Medication Prior Authorization Request Forms
Medication Request Forms (For Medicare)
- Diclofenac (Topical)
- High-Risk Medications
- High-Risk Non-Benzodiazepine Medications
- Skeletal Muscle Relaxants
- Lidocaine Patch and Ointment
- Hepatitis C Antivirals
Drug Coverage and Exceptions
In certain cases, a provider may determine that a member requires a non-covered prescription. When this occurs, you may submit a Request for Prescription Coverage Determination Form, or a Request for Prescription Redetermination Form if your previous request was denied. You can also call MedImpact Healthcare Systems for assistance at 1-888-678-7741.
If you are a provider in the VNSNY CHOICE Total network, you can use the following coverage determination and redetermination forms:
- Request for Medicare Prescription Drug Coverage Determination
- Request for Medicare Prescription Drug Coverage Redetermination
If you are a provider in the VNSNY CHOICE SelectHealth network, you can use the following coverage determination form:
If you need help, or need a Plan Appeal right away, call us at 1-888-678-7741 (TTY: 711).
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
Last updated 2/5/2020