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Pharmacy Prior Authorization Forms

NEW: Prescribers can now send electronic prior authorizations for drugs billed through the fee-for-service delivery system. For more information, an Electronic Prior Authorization information sheet is available on Medicaid’s website.

In order to obtain copies of prior authorization forms, please click on the name of the drug requiring prior authorization listed below. If you do not see the name of the drug needing prior authorization listed below you will need to select the Miscellaneous Pharmacy Prior Authorization Request form. If you need assistance, call (850) 412-4166.

These forms are (portable document format) files, which require the use of Acrobat Reader software. If you do not have Acrobat Reader, you may download the free software from the Adobe website.

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys [1.54MB] Updated 1/7/2019

Adult High Dose Antipsychotic [632KB] Updated 1/7/2019

Albumin [1.39MB] Updated 1/7/2019

Antidepressants (Age <6 years) [1.01MB] Updated 1/7/2019

Antipsychotic (Age <6 years of age) [1.52MB] Updated 1/7/2019

Antipsychotic (Age 6 to < 18 years of age) [1.65MB] Updated 1/9/2019

Buprenorphine Agents [1.9MB] Updated 5/24/2017

Cytogam [1.93MB] Updated 1/7/2019

Exondys [1.48MB] Updated 1/7/2019

Fuzeon [1.45MB] Updated 1/7/2019

Hepatitis C Agents [1.33MB] Updated 1/7/2019

HIV Diagnosis Verification [598KB] Updated 10/30/2017

Human Growth Hormone [1.26MB] Updated 1/7/2019

Increlex [1.65MB] Updated 1/9/2019

Miscellaneous Pharmacy Prior Authorization Requests [1.64MB] Updated 1/9/2019

Multi-Source Brand Drugs [1.36MB] Updated 1/9/2019 This form is to be used if a patient's prescription was not covered because there is a generic, and the prescribing physician believes the patient has had a bad reaction to the generic; or the brand drug is otherwise medically necessary.

Neupogen/Leukine/Neulasta/Granix/Zarxio/Fulphia/Nivestym [758KB] Updated 11/16/2018

Nityr [1.61MB] Updated1/9/2019

Opioids [1.69MB] Updated 1/9/2019

Oral Oncology Agents [1.66MB] Updated 1/9/2019

Orfadin [1.69MB] Updated 1/9/2019

Oxycontin [1.63MB] Updated 1/9/2019

Panretin [1.66MB] Updated 1/9/2019

Procrit/Aranesp [1.49MB] Updated 11/16/2018

Proleukin [1.23MB] Updated 1/11/2019

Selzentry [1.53MB] Updated 1/11/2019

Serostim [1.59MB] Updated 1/11/2019

Soma [647KB] Updated 1/11/2019

Spinraza [1.43MB] Updated 1/11/2019

Stimulants and Strattera (<6 years of age) [1.43MB] Updated 1/11/2019

Supprelin LA [1.58MB] Updated 1/11/2019

Synagis - All Florida Regions Combined [1.87MB] Updated 1/11/2019

Synagis - Weight Change [1.42MB] Updated 1/11/2019

Vfend [1.57MB] Updated 1/11/2019