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
[
20.2 kB
]
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 MB
]
Updated 1/3/2025
Adult High Dose Antipsychotic
[
634.1 kB
]
Updated 1/3/2025
Albumin
[
1.1 MB
]
Updated 1/3/2025
Antidepressants (Age <6 years)
[
1.4 MB
]
Updated 1/3/2025
Antipsychotic (Age <6 years of age)
[
1.4 MB
]
Updated 1/3/2025
Antipsychotic (Age 6 to < 18 years of age)
[
1.9 MB
]
Updated 1/3/2025
Colony Stimulating Factors
[
1.3 MB
]
Updated 1/3/2025
Cytogam
[
1 MB
]
Updated 1/3/2025
Erythropoeisis Stimulating Agents Form
[
1 MB
]
Updated 1/3/2025
Exondys
[
1 MB
]
Updated 1/3/2025
Fuzeon
[
1 MB
]
Updated 1/3/2025
Hepatitis C Agents
[
1.9 MB
]
Updated 1/3/2025
HIV Diagnosis Verification or Prophylaxis of HIV Form
[
1.4 MB
]
Updated 1/3/2025
Human Growth Hormone
[
1.4 MB
]
Updated 1/3/2025
Increlex
[
1.3 MB
]
Updated 1/3/2025
Miscellaneous Pharmacy Prior Authorization Requests
[
897.7 kB
]
Updated 1/3/2025
Multi-Source Brand Drugs
[
992.3 kB
]
Updated 1/3/2025 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.
Opioids
[
547.5 kB
]
Updated 1/3/2025
Oral Oncology Agents
[
1.3 MB
]
Updated 1/3/2025
Orfadin/Nityr (Nitisinone)
[
1.3 MB
]
Updated 1/16/2025
Panretin
[
1.3 MB
]
Updated 1/3/2025
Proleukin
[
1.3 MB
]
Updated 1/3/2025
Selzentry
[
966.2 kB
]
Updated 1/3/2025
Serostim
[
1 MB
]
Updated 1/16/2025
Soma
[
1.5 MB
]
Updated 1/3/2025
Spinraza
[
1 MB
]
Updated 1/3/2025
Stimulants and Strattera (<6 years of age)
[
1.1 MB
]
Updated 1/3/2025
Supprelin LA
[
532.2 kB
]
Updated 1/3/2025
Synagis - All Florida Regions Combined
[
1.4 MB
]
Updated 1/3/2025
Synagis - Weight Change
[
1 MB
]
Updated 1/3/2025
Vfend
[
1.1 MB
]
Updated 1/3/2025
