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.
Covered Services, Authorizations & Limitations
Authorization Request Form
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.
You may also initiate a coverage determination:
- By phone at 1-844-782-7670
- Through EnvisionRx’s website. Visit https://envision.promptpa.com
Appoint a Representative