Learn more
Just see our provider manual. Or contact us.
Pharmacy PA guidelines
We use the criteria set by the Agency for Health Care Administration (AHCA) along with our own custom prior authorization guidelines to make decisions about PA. If you’d like a copy of the guidelines sent to you or have questions, just call Provider Relations:
- Medicaid MMA: 1-800-441-5501 (TTY: 711)
- FHK: 1-844-528-5815 (TTY: 711)
You can find the related PA request forms here.
All signed pharmacy PA request forms should be faxed to 1-855-799-2554
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Advate, Hemofil M, Kogenate FS, Novoeight, Recombinate, Xyntha (PDF)
Adynovate, Altuviiio, Eloctate, Esperoct (PDF)
Afstyla, Kovaltry, Nuwiq (PDF)
Antidiabetic Agents - Exenatide, Liraglutide, Ozempic, Segluromet, Steglatro (PDF)
Atypical antipsychotic oral and transdermal (PDF)
CGRP Antagonists Injectable IV Infusion (PDF)
CGRP Antagonists Oral Nasal (PDF)
Compounded drug products (PDF)
Continuous glucose monitor (PDF) applies to Florida Healthy Kids
Diabetic test strips (PDF) applies to Florida Healthy Kids
Disposable insulin pumps (PDF)
Eltrombopag olamine and Alvaiz (PDF)
Epogen - Procrit - Retacrit (PDF)
Fentanyl products - oral and intranasal (PDF)
Immune Globulin Intravenous (PDF)
Immune Globulin Subcutaneous (PDF)
Infliximab Remicade and Biosimilars (PDF)
Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)
Lupron Depot Endometriosis - Fibroids (PDF)
Lupron Depot Prostate Cancer (PDF)
Methylphenidate products (PDF)
Metronidazole topical gel 1 percent (PDF)
Neulasta and pegfilgrastim biosimilars (PDF)
Neupogen and filgrastim biosimilars (PDF)
Nitroglycerin 0.4 percent ointment (PDF)
Opioid analgesics extended-release (PDF)
Opioid analgesics immediate-release (PDF)
Proton Pump Inhibitors Post Limit (PDF)
Radicava oral suspension (PDF)
Ranolazine extended-release (PDF)
Ribavirin 200mg capsules and tablets (PDF)
Electronic PA (ePA)
You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide a new way to request a pharmacy PA with our ePA program.
With ePA, you can look forward to saving time with:
Less paperwork
Fewer phone calls and faxes
Quicker determinations
Safe and secure HIPAA-compliant submitted requests
Easy upload of clinical documents
Enroll now
Getting started with ePA is free and easy. You’ll need this info to enroll:
- BIN: 610591
- GRP: RX8840
- PCN: ADV
You can enroll two different ways:
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You can enroll with CoverMyMeds online. Or call 1-866-452-5017.
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You can enroll with Surescripts online. Or call 1-866-797-3239.
Other ways to request PA
If you don’t want to enroll in ePA, you can request PA:
By phone
By fax
Check “PA request forms” in the next section to find the right form. Then, fax it with any supporting documentation for a medical necessity review to 1-855-799-2554.
PA request forms
If you don’t see the right form on the list in this section, you can use the miscellaneous request form (PDF) for Medicaid MMA or the universal pharmacy PA request form (PDF) for FHK. Otherwise, check for the drug class or drug name that matches your needs:
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If you don’t see the right form on the list, you can use the miscellaneous request form (PDF). Otherwise, check for the drug class or drug name that matches your needs. Reference AHCA criteria to complete a miscellaneous request form when a drug specific form is not available. Scroll to the top of this page to find additional criteria. Find Medicaid MMA guidelines and click on the down arrow to display a chart of guidelines as well as individually posted guidelines.
If submitting a request for a brand that is not on the PDL, just complete the multi-source brand drug form (PDF) and submit along with the PA form
- Actiq (PDF)
- Adult Antipsychotic High Dose (PDF)
- Albumin (PDF)
- Antidepressants Under 6 Years (PDF)
- Antipsychotics Under 18 Years (PDF)
- Antipsychotics Under 6 Year (PDF)
- Colony Stimulating Factors (PDF)
- Cytogam (PDF)
- Erythropoeitin Stimulating Agents (PDF)
- Exondys (PDF)
- Fuzeon (PDF)
- General PA form (may be used to submit requests for medical procedures) (PDF)
- HIV diagnosis verification form (PDF)
- Hepatitis C agents (PDF)
- Human Growth Hormone (PDF)
- Increlex (PDF)
- Off-label use criteria (PDF)
- Oncology, oral (PDF)
- Opioids (PDF)
- Orfadin (PDF)
- Panretin (PDF)
- Proleukin (PDF)
- Selzentry (PDF)
- Serostim (PDF)
- Soma (PDF)
- Spinraza (PDF)
- Stimulant Less Than 6 Years (PDF)
- Supprelin LA (PDF)
- Synagis (PDF)
- Synagis Weight Change (PDF)
- Vfend (PDF)
- Zolgensma (PDF)
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If you don’t see the right form on the list, you can use the universal pharmacy PA request form (PDF). Otherwise, check for the drug class or drug name that matches your needs. Scroll to the top of this page to find criteria specific to Florida Healthy Kids. Find FHK guidelines and click on the down arrow to display a chart of guidelines as well as individually posted guidelines.
If submitting a request for a brand that is not on the PDL, just complete the Food and Drug Administration Med Watch form (PDF) and submit along with the PA form.
CoverMyMeds is a registered trademark of CoverMyMeds LLC.