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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:

 

 

Florida Healthy Kids non-formulary and prior authorization guidelines (PDF)

 

Global Exception (PDF)

 

Acamprosate (PDF)

 

Actemra (PDF)

 

Actimmune (PDF)

 

Adbry (PDF)

 

Adzynma (PDF)

 

Agamree (PDF)

 

Ambrisentan-Letairis (PDF)

 

Amphetamine Products (PDF)

 

Anthelmintics (PDF)

 

Aranesp (PDF)

 

Arcalyst (PDF)

 

Aripiprazole Injection (PDF)

 

Armodafinil (PDF)

 

Atypical Antipsychotic Oral and Transdermal (PDF)

 

Aubagio (PDF)

 

Austedo-Austedo XR (PDF)

 

Avonex (PDF)

 

Bafiertam (PDF)

 

Berinert (PDF)

 

Betaseron - Extavia (PDF)

 

Bimzelx (PDF)

 

Bosentan-Tracleer (PDF)

 

Botox (PDF)

 

CGRP Antagonists Injectable IV Infusion (PDF)

 

CGRP Antagonists Oral Nasal (PDF)

 

Cablivi (PDF)

 

Calcipotriene (PDF)

 

Cayston (PDF)

 

Cequa and Cyclosporin Ophthalmic Emulsion (PDF)

 

Cibinqo (PDF)

 

Cimzia (PDF)

 

Cinqair (PDF)

 

Cinryze (PDF)

 

Compounded Drug Products (PDF)

 

Continuous Glucose Monitor (PDF)

 

Copaxone - Glatopa (PDF)

 

Corlanor (PDF)

 

Cosentyx (PDF)

 

Dalfampridine (PDF)

 

Daxxify (PDF)

 

Daybue (PDF)

 

Diabetic Test Strips (PDF)

 

Diacomit (PDF)

 

Dificid (PDF)

 

Dupixent (PDF)

 

Duvyzat (PDF)

 

Dysport (PDF)

 

Egrifta (PDF)

 

Eligard (PDF)

 

Emflaza (PDF)

 

Enbrel (PDF)

 

Endari (PDF)

 

Entresto (PDF)

 

Entyvio (PDF)

 

Eohilia (PDF)

 

Epclusa (PDF)

 

Epidiolex (PDF)

 

Epogen - Procrit - Retacrit (PDF)

 

Epoprostenol-Flolan-Veletri (PDF)

 

Esbriet (PDF)

 

Eucrisa (PDF)

 

Evenity (PDF)

 

Evrysdi (PDF)

 

Exondys 51 (PDF)

 

Fabhalta (PDF)

 

Factor VIII (PDF)

 

Factor IX (PDF)

 

Fasenra (PDF)

 

Feiba (PDF)

 

Fensolvi (PDF)

 

Filspari (PDF)

 

Filsuvez (PDF)

 

Forteo - Teriparatide (PDF)

 

GamaSTAN (PDF)

 

Gilenya - Tascenso (PDF)

 

Griseofulvin (PDF)

 

Growth hormone (PDF)

 

HP Acthar (PDF)

 

Haegarda (PDF)

 

Hemlibra (PDF)

 

Hetlioz (PDF)

 

Humira and Biosimilars (PDF)

 

Icatibant - Sajazir - Firazyr (PDF)

 

Icosapent Ethyl (PDF)

 

Ilaris (PDF)

 

Ilumya (PDF)

 

Immune Globulin Intravenous (PDF)

 

Immune Globulin Subcutaneous (PDF)

 

Increlex (PDF)

 

Infliximab Remicade and Biosimilars (PDF)

 

Ingrezza (PDF)

 

Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)

 

Invega Hafyera (PDF)

 

Invega Sustenna (PDF)

 

Invega Trinza (PDF)

 

Jardiance (PDF)

 

Joenja (PDF)

 

Juxtapid (PDF)

 

Kalydeco (PDF)

 

Kesimpta (PDF)

 

Kevzara (PDF)

 

Kineret (PDF)

 

Korlym (PDF)

 

Krystexxa (PDF)

 

Lemtrada (PDF)

 

Leqvio (PDF)

 

Leukine (PDF)

 

Leuprolide (PDF)

 

Linezolid (PDF)

 

Linzess (PDF)

 

Litfulo (PDF)

 

Lodoco (PDF)

 

Lubiprostone (Amitiza) (PDF)

 

Lupron Depot Endometriosis - Fibroids (PDF)

 

Lupron Depot PED (PDF)

 

Lupron Depot Prostate Cancer (PDF)

 

Mavenclad (PDF)

 

Mavyret (PDF)

 

Methylphenidate Products (PDF)

 

Mayzent (PDF)

 

Miglustat Products (PDF)

 

Mircera (PDF)

 

Modafinil (PDF)

 

Mounjaro (PDF)

 

Movantik (PDF)

 

Mulpleta (PDF)

 

Multaq (PDF)

 

Myobloc (PDF)

 

Neulasta and pegfilgrastim biosimilars (PDF)

 

Neupogen and filgrastim biosimilars (PDF)

 

Ngenla (PDF)

 

Novoseven RT (PDF)

 

Nucala (PDF)

 

Obizur (PDF)

 

Ocrevus (PDF)

 

Octreotide (PDF)

 

Ofev (PDF)

 

Olumiant (PDF)

 

Omvoh (PDF)

 

Onychomycosis (PDF)

 

Opsumit (PDF)

 

Orencia (PDF)

 

Orenitram (PDF)

 

Orilissa (PDF)

 

Orkambi (PDF)

 

Oxbryta (PDF)

 

Oxervate (PDF)

 

Ozempic and Trulicity (PDF)

 

Palforzia (PDF)

 

Pegasys (PDF)

 

Penicillamine Trientine (PDF)

 

Plegridy (PDF)

 

Pombiliti (PDF)

 

Ponvory (PDF)

 

Praluent (PDF)

 

Pregabalin Immediate Release (PDF)

 

Prolia (PDF)

 

Promacta-Alvaiz (PDF)

 

Proton Pump Inhibitors Post Limit (PDF)

 

Pyrimethamine (PDF)

 

Rebif (PDF)

 

Recorlev (PDF)

 

Rectiv (PDF)

 

Repatha (PDF)

 

Reyvow (PDF)

 

Redziffra (PDF)

 

Rifloza (PDF)

 

Rinvoq (PDF)

 

Riociguat-Adempas (PDF)

 

Risperdal Consta (PDF)

 

Rivastigmine Patch (PDF)

 

Roflumilast (PDF)

 

Ruconest (PDF)

 

Rystiggo (PDF)

 

Sensipar (cinacalcet) (PDF)

 

Serostim (PDF)

 

Sevenfact (PDF)

 

Signifor (PDF)

 

Signifor LAR (PDF)

 

Sildenafil, Revatio, Liqrev (PDF)

 

Siliq (PDF)

 

Simponi (PDF)

 

Simponi Aria (PDF)

 

Skyclarys (PDF)

 

Skyrizi (PDF)

 

Skytrofa (PDF)

 

Sogroya (PDF)

 

Sohonos (PDF)

 

Soliris (PDF)

 

Somavert (PDF)

 

Sotyktu (PDF)

 

Spevigo (PDF)

 

Spiriva Respimat (PDF)

 

Spinraza (PDF)

 

Stelara (PDF)

 

Sunosi (PDF)

 

Supprelin LA (PDF)

 

Symdeko (PDF)

 

Symlin (PDF)

 

Symproic (PDF)

 

Synarel (PDF)

 

Tacrolimus Ointment (PDF)

 

Tadalafil Products (PDF)

 

Takhzyro (PDF)

 

Taltz (PDF)

 

Tavalisse (PDF)

 

Tecfidera (PDF)

 

Tepezza (PDF)

 

Testosterone (PDF)

 

Tetrabenazine (PDF)

 

Tezspire (PDF)

 

Tobramycin Inhalation (PDF)

 

Trelegy (PDF)

 

Tremfya (PDF)

 

Treprostinil-Remodulin (PDF)

 

Trikafta (PDF)

 

Trelstar (PDF)

 

Triptodur (PDF)

 

Tymlos (PDF)

 

Tyrvaya (PDF)

 

Tysabri (PDF)

 

Tyvaso (PDF)

 

Uptravi (PDF)

 

Velsipity (PDF)

 

Ventavis (PDF)

 

Veopoz (PDF)

 

Veozah (PDF)

 

Vonvendi (PDF)

 

Voriconazole (PDF)

 

Vowst (PDF)

 

Voydeya (PDF)

 

Vumerity (PDF)

 

Vyvgart - Vyvgart Hytrulo (PDF)

 

Wainua (PDF)

 

Wakix (PDF)

 

Wilate (PDF)

 

Xeljanz and Xeljanz XR (PDF)

 

Xeomin (PDF)

 

Xiidra (PDF)

 

Xolair (PDF)

 

Xphozah (PDF)

 

Xyrem - sodium oxybate (PDF)

 

Xywav (PDF)

 

Zeposia (PDF)

 

Zilbrysq (PDF)

 

Zoledronic Acid - Reclast - Zometa (PDF)

 

Zurzuvae (PDF)


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. 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) 

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 the medication you need to request is not found in the chart or listed individually, reference the AHCA criteria.    

 

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.

 

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

  

Hepatitis C agents (PDF) 

  

Off-label use criteria (PDF) 

  

Oncology, oral (PDF) 

  

Opioids (PDF)

   

Synagis (PDF)

 

Synagis Weight Change (PDF)

Learn more about PA

 

Non-pharmacy PA

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