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
- Synagis Request Form
- Yescarta Request Form