Skip to main content

Pharmacy prior authorization (PA)

Medicaid Managed Medical Assistance (MMA) and Florida Healthy Kids (FHK) each have their own preferred drug list (PDL). When a medication isn't on the PDL, or has a utilization management requirement, you’ll want to request pharmacy PA. You can review our current guidelines.

Learn more

Just see our provider manual. Or contact us.

Pharmacy PA guidelines

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:

 

 


You can find the related PA request forms here.

 

All signed pharmacy PA request forms should be faxed to 1-855-799-2554

Electronic PA (ePA)

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:

Other ways to request PA

 

If you don’t want to enroll in ePA, you can request PA:

By phone

Just call Provider Relations:

 

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:

 

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.

 

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

  

Epaned (PDF) 

  

Erythromycin (PDF) 

  

Ferriprox (PDF) 

  

Fetzima (PDF) 

  

Folbic (PDF) 

  

Forteo (PDF) 

  

Fuzeon (PDF) 

  

Fycompa (PDF) 

  

General PA form (may be used to submit requests for medical procedures) (PDF) 

  

Glucocorticoids Oral (PDF) 

  

HIV diagnosis verification form (PDF) 

  

Hemangeol (PDF) 

  

Hepatitis C agents (PDF) 

  

HP Acthar Gel (PDF)

  

Hyaluronic acid derivatives (PDF) 

  

Juxtapid (PDF) 

  

Kalydeco-Orkambi-Symdeko-Trikafta (PDF) 

  

Kapvay (PDF) 

  

Kepivance (PDF) 

  

Lamictal XR (PDF) 

  

Luxturna (PDF) 

  

Marinol (PDF) 

  

Metadate CD (PDF) 

  

Methadone (PDF) 

  

Morphine Sulfate (PDF) 

  

Mozobil (PDF) 

  

Multi-source brand (PDF) 

  

Myrbetriq (PDF) 

  

Namenda XR (PDF) 

  

Natacyn (Natamycin) (PDF) 

  

Neupro (PDF) 

  

Nimotop (PDF) 

  

Nuplazid (PDF) 

  

Off-label use criteria (PDF) 

  

Oncology, oral (PDF) 

  

Onfi (PDF) 

  

Opioids (PDF)

  

Otrexup (PDF) 

  

Oxandrin (Oxyandrolone) (PDF) 

  

Oxtellar XR (PDF) 

  

Potiga (PDF) 

  

ProCentra (PDF) 

  

Provigil (PDF) 

  

Pylera (PDF) 

  

Qudexy XR (PDF) 

  

Rasuvo (PDF) 

  

Reclast (PDF) 

  

Rexulti (PDF) 

  

Sabril (PDF) 

  

Samsca (PDF) 

  

Sanctura (PDF) 

  

Sancuso (PDF) 

  

Selzentry (PDF) 

  

Skeletal muscle relaxant (PDF) 

  

Spinraza (PDF) 

  

Synagis (PDF) 

  

Tepezza (PDF) 

  

Trokendi XR (PDF) 

  

Valcyte (PDF)

  

Vecamyl (PDF) 

  

Viberzi (PDF) 

  

Vimizim (PDF) 

  

Vivitrol (PDF) 

  

Xenazine (PDF) 

  

Xermelo (PDF) 

  

Xifaxan (PDF) 

  

Xopenex (PDF) 

  

Zolgensma (PDF) 

  

Zyprexa (PDF) 

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.

 

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.

 

Epaned (PDF) 

  

Erythromycin (PDF)

  

Fentanyl (transmucosal IR) (PDF) 

  

Ferriprox (PDF) 

  

Folbic (PDF) 

  

Forteo (PDF) 

  

Fycompa (PDF) 

  

General PA form (to submit requests for medical procedures) (PDF) 

  

Glucocorticoids, oral (PDF) 

  

Hemangeol (PDF) 

  

Hepatitis C agents (PDF) 

  

HP Acthar Gel (PDF) 

  

Hyaluronic acid derivatives (PDF) 

  

Juxtapid (PDF) 

  

Kalydeco-Orkambi-Symdeko-Trikafta (PDF) 

  

Kapvay (PDF) 

  

Kepivance (PDF)

  

Lamictal XR (PDF) 

  

Linzess (PDF) 

  

Lovaza (PDF) 

  

Luxturna (PDF) 

  

Marinol (PDF) 

  

Metadate CD (PDF) 

  

Methadone (PDF) 

  

Morphine Sulfate ER (PDF) 

  

Mozobil (PDF) 

  

Multi-source brand (PDF)

  

Namenda XR (PDF) 

  

Natacyn (Natamycin) (PDF) 

  

Neupro (PDF

  

Nimotop (PDF) 

  

Nucynta (PDF) 

  

Nuedexta (PDF) 

  

Nuplazid (PDF) 

  

Off-label use criteria (PDF) 

  

Oncology, oral (PDF) 

  

Onfi (PDF) 

  

Opioids (PDF)

  

Otrexup (PDF) 

Oxandrin (Oxyandrolone) (PDF) 

  

Oxtellar XR (PDF) 

  

Panretin (PDF) 

  

Potiga (PDF) 

  

Proton pump inhibitors (PPI) post limit (PDF) 

  

ProCentra (PDF) 

  

Provigil (PDF) 

  

Pylera (PDF) 

  

Qudexy XR (PDF) 

  

Rasuvo (PDF) 

  

Reclast (PDF)

  

Rexulti (PDF)

  

Sabril (PDF) 

  

Samsca (PDF) 

  

Sanctura (PDF) 

  

Sancuso (PDF

  

Saphris (PDF) 

  

Selzentry (PDF)

  

Skeletal muscle relaxant (PDF) 

  

Soma, Soma compound (PDF) 

  

Spinraza (PDF) 

  

Sylatron (PDF) 

  

Synagis (PDF) 

  

Tepezza (PDF)

  

Trokendi (PDF) 

  

Valcyte (PDF) 

  

Vecamyl (PDF) 

  

Vfend (PDF) 

  

Viberzi (PDF) 

  

Vimizim (PDF) 

  

Vivitrol (PDF) 

  

Xenazine (PDF) 

  

Xermelo (PDF) 

  

Xifaxan (PDF) 

  

Xopenex (PDF) 

  

Zolgensma (PDF) 

  

Zyprexa (PDF) 

Learn more about PA

 

Non-pharmacy PA

CoverMyMeds is a registered trademark of CoverMyMeds LLC.

Also of interest: