Utilization Management & Authorizations

Authorizations are subject to a member’s eligibility, enrollment status and covered benefits. The forms below will help ensure appropriate treatment plans and resources are utilized to manage all members’ health care needs. Please also refer to the Utilization Management Guidelines.opens PDF file

Covered Services, Authorizations & Limitations

• LiveWellopens PDF file
• FeelWellopens PDF file
• CareWellopens PDF file
• MAPopens PDF file

Authorization Request Form

• Prior Authorization Request Formopens PDF file
• Medicare Non-Emergent Ambulanceopens PDF file

Pharmacy Exceptions and Coverage Determinations

If you require a medication that is not on the AgeWell New York formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules or tiered cost-sharing, you have the right to request a coverage determination. Review the information below to learn more.

• Coverage Determination Formopens PDF file
• Redetermination Request Formopens PDF file
• Tier Exception Request Formopens PDF file
• Non-Formulary Exception Request Formopens PDF file

You may also initiate a coverage determination:

By calling 1-800-361-4542
Through Elixir website at elixirsolutions.promptpa.com
By mailing your request to:
Elixir
7835 Freedom Avenue NW
North Canton, OH 44720

Appoint a Representative

• Appointment of Representative Form – Englishopens PDF file
• Appointment of Representative Form – Spanishopens PDF file