Provider Tool Kit

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Provider Tool Kit

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Medication Prior Authorization Request Forms

Medication Request Forms (For Medicare) 

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:

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

Find a Network Provider

Find a physician, pharmacy or other provider in the VNSNY CHOICE network.

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