Authorization Criteria and Clinical Guidelines

The following are medications with specific clinical guidelines and prior authorization criteria (click in each medication for more details):
For Hormone Replacement Therapy call 646-786-1800.
Cimzia
Growth Hormone
Increlex
Kineret
Lidoderm
Nuvigil
Provigil
Oral Transmucosal Fentanyl Drugs
Phosphodiesterase-5 (PDE-5) Inhibitors for PAH
Regranex Gel
Simponi
Synagis
Zyvox

Prior Authorization Forms: Please use these forms in order to expedite the process of obtaining a Prior Authorization for the medications listed below. Once the form is completed, it can be faxed to Express Scripts. Please be sure to include ALL relevant information requested as a lack of information will lead to delays in Prior Authorization attainment. The General Request Form can be used in order to INITIATE a Prior Authorization for ANY medication, but please be aware that additional information may be needed in order to complete the request. Express Scripts will contact you via fax for any additional information that is needed in order to complete the request. Additionally, you may be required to provide information regarding your request to a live Express Scripts representative via telephone.

Gereral Request
Lidoderm
Nuvigil
Provigil

Amida Care is an NYS sponsored HIV Special Needs Plan (SNP) that provides health care services for people on Medicaid living with HIV and their children. Amida Care services Manhattan, Brooklyn, the Bronx and Staten Island. Starting September 1, 2010, if you live in New York City, choosing a Special Needs Plan or a regular Medicaid managed care plan is mandatory for PLWHA. To learn more about HIV SNPs, call NY Medicaid CHOICE helpline at 1-800-505-5678. (TTY 1-888-329-1541)

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