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NY

New York Prior Authorization Requirements

Medicare TraditionalMedicaid MCOMedicaid FFSMedicare AdvantagePart DDual-EligibleCommercial (employer / fully-insured)NY Medicaid Rx

PA required

72%

296 verified rules

Verified May 22, 2026

Service category PA

All programs combined
Durable Medical Equipment
9/10Conditional
Specialty Drugs
9/10Conditional
Inpatient Hospital
8/10Conditional
Skilled Nursing Facility
8/10Conditional
Outpatient Surgery
8/10Conditional
Mental Health — Inpatient
8/10Conditional
Home Health
8/10Conditional
Physical Therapy
7/10Conditional
Ambulance Transport
7/10Conditional
Occupational Therapy
7/10Conditional
Speech Therapy
7/10Conditional
Diagnostic Imaging
7/10Conditional
Substance Use Treatment
7/10Conditional
advanced_imaging
7/10Conditional
Laboratory
0/10No PA

Drug class PA

Part D federal protections flagged
Immunosuppressants
7/9Conditional
Rare Disease / Orphan
7/8Conditional
Specialty Non-Biologic
6/7Conditional
Controlled — Schedule II
6/7Conditional
Biosimilars
6/7Conditional
Diabetes — Insulin
6/7Conditional
Brand (Generic Available)
6/7Conditional
Antipsychotics
6/8Conditional
Specialty Biologics
6/7Conditional
Diabetes — Non-Insulin
6/7Conditional
Controlled — Schedule III–V
6/7Conditional
ADHD Stimulants
6/7Conditional
Brand (No Generic)
6/7Conditional
Hepatitis C
6/7Conditional
Oral Oncology
5/7Conditional
Antidepressants
5/7Conditional
HIV Antiretrovirals
5/7Conditional
GLP-1 (Weight Loss)
2/7Conditional
Compounded Medications
1/7Conditional
otc_covid_antigen_test
1/1Full PA
glp1_diabetes
1/1Full PA
Opioid Treatment (MOUD)
0/7No PA

PA type breakdown

Conditional
125
Full PA
83
clinical_criteria
4

Federal protected classes requiring PA

AntipsychoticsPA required
AntidepressantsPA required
AntidepressantsPA required
HIV AntiretroviralsPA required
AntipsychoticsPA required
Oral OncologyPA required
HIV AntiretroviralsPA required
ImmunosuppressantsPA required
ImmunosuppressantsPA required
Oral OncologyPA required

State flags

Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)

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