Workflow of a Request – Where the request needs to be sent.
Workflow of a Request – New Century Health
- Portal: https://my.newcenturyhealth.com
- Fax: 877-624-8602
- Phone: 888-999-7713
Please go to Cover My Meds to initiate a request.
General Forms
- Quantity Limit Exception Form
- Exception Criteria Form– For use with drugs that require a Prior Authorization, Quantity Limit, or are Non-Formulary
- Step Therapy Criteria Form– For use with drugs that require Step Therapy
- Long Acting Opioid Prior Authorization Form
- Short Acting Opioid Prior Authorization Form
Drug Specific Request Forms
- Botox Request Form
- Hemophilia Case Review Form
- Hemophilia Prior Authorization Form
- Hepatitis C Prior Authorization Form
- Hetlioz Commercial PA Form
- Kymriah Request Form
- Yescarta Request Form
For the 2023/24 Synagis season, Neighborhood Health Plan of Rhode Island will prefer Beyfortus (nirsevimab), a long-acting monoclonal antibody, administered once to all neonates and infants entering their first RSV season as well as children up to 24 months who are high risk. Beyfortus will not require a prior authorization and will be available as a State Supplied Vaccine.
To obtain prophylactic treatment with Synagis, which requires six monthly injections, prescribers will need to submit a prior authorization documenting why the member is unable to utilize Beyfortus and clinical rationale showing the necessity of Synagis. To view Neighborhood’s Synagis Prior Authorization Criteria visit this page.