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.
Coverage Determination Form
Tier Exception Request Form
Non-Formulary Exception Request Form

You may also initiate a coverage determination:

Appoint a Representative

Appointment of Representative form (English)