Pharmacy Prior Authorization Forms

To submit a request for pharmacy prior authorization, please fax your request to 1-855-799-2554 and include all documentation to support the medical necessity review. You can also submit your request by phone by calling:

Medicaid at 1-800-441-5501
Florida Healthy Kids at 1-844-528-5815

For prior authorization requests for drugs or drug classes not listed below, please fax in your request to 1-855-799-2554 on the General PA Form with supporting clinical information.

To quickly find a prior authorization form, press CTRL F on your keyboard and type in the form name.

Universal Pharmacy Prior Authorization Request Form

Miscellaneous Request Form

 

5-ASA Derivatives Oral Preparations

Abilify Maintena

Abstral-Actiq-Fentora-Lazanda-Onsolis-Subsys

Abuse Deterrent Products

Adcetris

Adult High Dose Antipsychotic

Albumin

Aldurazyme

Alinia

Aloxi

Altabax

Amitiza

Anti-Migraine Agents

Aplenzin

Apokyn

Aptiom

Aristada

Atrovent Nasal Spray

Aubagio

Austedo

Banzel

Bone Resorption Inhibitor

Boniva Injection

Botulinum Toxins  

Buprenorphine 

Butalbital Products

Calcitonon Gene-Related Peptide Receptors (Aimovig, Nurtec ODT, Ubrelvy, Ajovy, Vyepti, Emgality) New 08.18.2020

Carbaglu

Cayston

Ceprotin

Chemet

Chorionic Gonadotropin

CII-CV Edit Overrides

Cinqair

Colcrys

Corifact

Colony Stimulating Factors NEW 07.31.2020

Cough and Cold Codeine Containing Medications

Crysvita

Cyanobobalamin

Cyramza  

Cytokine and CAM Antagonists  Updated 08.07.2020

Dalfampridine (Ampyra)  

Daliresp

Dalvance

Daraprim

Detrol/Detrol LA

Diastat

Dibenzyline

Diclegis

Dificid

Dupixent  

Elaprase

Elmiron

Epaned

Erythromycin

Erythropoiesis Stimulating Agents NEW 07.31.2020

Exjade

Fasenra

Fentanyl (Transmucosal IR)

Ferriprox

Fetzima

Folbic

Forteo

Fulyzaq

Fycompa

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

Gilenya

Glucocorticoids Oral

Growth Hormone 

Hemangeol

Hepatitis C  Updated 09.12.2020

Hetlioz

HP Arthar Gel

Hyaluronic Acid Derivatives

Ingrezza

Invega Sustenna

Invega Tablets

Invega Trinza

IVIG

Jardiance

Juxtapid

Kalydeco-Orkambi-Symdeko-Trikafta 

Kapvay

Kepivance

Kynamro

Lacrisert

Lamictal XR

Linzess

Lioresal/Gablofen

Long Acting Stimulants in Children Under Six Years of Age

Long-Acting Beta Agonists

Lovaza

Luxturna

Marinol

Metadate CD

Methadone

Morphine Sulfate

Mozobil

Multi Source Brand

Myrbetriq

Namenda XR

Natacyn (Natamycin)

Neulasta

Neupro

Neumega

Nimotop

Nityr

Nucala

Nucynta

Nuedexta

Nuplazid

Off Label Use Criteria

Oncology - Oral  

Onfi

Opioids  

Otrexup

Oxandrin (Oxyandrolone)

Oxtellar XR

Oxycontin

Panretin

Platelet Inhibitor (Zontivity)

Potiga

PPI Post Limit

ProCentra

Provigil

Pylera

Qudexy XR

Rasuvo

Reclast

Relistor

Repatha

Rexulti

Risperdal Consta

Sabril

Samsca

Sanctura

Sancuso

Sandostatin

Saphris

Selzentry

Sensipar

Serostim

Skelatal Muscle Relaxant

Soma-Soma Compound

Spinraza

Supprelin LA

Sylatron

Synagis  

Tavalisse 

Tecfidera

Testosterone

Trogarzo

Trokendi

Tygacil

Tymlos

Valcyte

Vecamyl

Venofer

Veregen

Vfend

Vibativ

Viberzi

Vimizim

Vivitrol

Xenazine

Xermelo

Xifaxan

Xopenex

Yescarta

Zolgensma  

Zyprexa

Zyvox

To quickly find a prior authorization form, press CTRL F on your keyboard and type in the form name.

Universal Pharmacy Prior Authorization Request Form

Miscellaneous Request Form

 

5-ASA Derivatives Oral Preparations

Abilify Maintena

Abstral-Actiq-Fentora-Lazanda-Onsolis-Subsys

Abuse Deterrent Products

Adcetris

Adult High Dose Antipsychotic

Albumin

Aldurazyme

Alinia

Aloxi

Altabax

Amitiza

Anti-Migraine Agents

Aplenzin

Apokyn

Aptiom

Aristada

Atrovent Nasal Spray

Aubagio

Austedo

Banzel

Bone Resorption Inhibitor

Boniva Injection

Botulinum Toxins  

Buprenorphine 

Butalbital Products

Calcitonon Gene-Related Peptide Receptors (Aimovig, Nurtec ODT, Ubrelvy, Ajovy, Vyepti, Emgality) New 08.18.2020

Carbaglu

Cayston

Ceprotin

Chemet

Chorionic Gonadotropin

CII-CV Edit Overrides

Cinqair

Colcrys

Corifact

Colony Stimulating Factors NEW 07.31.2020

Cough and Cold Codeine Containing Medications

Crysvita

Cyanobobalamin

Cyramza  

Cytokine and CAM Antagonists  Updated 08.07.2020

Dalfampridine (Ampyra)  

Daliresp

Dalvance

Daraprim

Detrol/Detrol LA

Diastat

Dibenzyline

Diclegis

Dificid

Dupixent  

Elaprase

Elmiron

Epaned

Erythromycin

Erythropoiesis Stimulating Agents NEW 07.31.2020

Exjade

Fasenra

Fentanyl (Transmucosal IR)

Ferriprox

Fetzima

Folbic

Forteo

Fulyzaq

Fycompa

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

Gilenya

Glucocorticoids Oral

Growth Hormone 

Hemangeol

Hepatitis C  Updated 09.12.2020

Hetlioz

HP Arthar Gel

Hyaluronic Acid Derivatives

Ingrezza

Invega Sustenna

Invega Tablets

Invega Trinza

IVIG

Jardiance

Juxtapid

Kalydeco-Orkambi-Symdeko-Trikafta 

Kapvay

Kepivance

Kynamro

Lacrisert

Lamictal XR

Linzess

Lioresal/Gablofen

Long Acting Stimulants in Children Under Six Years of Age

Long-Acting Beta Agonists

Lovaza

Luxturna

Marinol

Metadate CD

Methadone

Morphine Sulfate

Mozobil

Multi Source Brand

Myrbetriq

Namenda XR

Natacyn (Natamycin)

Neulasta

Neupro

Neumega

Nimotop

Nityr

Nucala

Nucynta

Nuedexta

Nuplazid

Off Label Use Criteria

Oncology - Oral  

Onfi

Opioids  

Otrexup

Oxandrin (Oxyandrolone)

Oxtellar XR

Oxycontin

Panretin

Platelet Inhibitor (Zontivity)

Potiga

PPI Post Limit

ProCentra

Provigil

Pylera

Qudexy XR

Rasuvo

Reclast

Relistor

Repatha

Rexulti

Risperdal Consta

Sabril

Samsca

Sanctura

Sancuso

Sandostatin

Saphris

Selzentry

Sensipar

Serostim

Skelatal Muscle Relaxant

Soma-Soma Compound

Spinraza

Supprelin LA

Sylatron

Synagis  

Tavalisse 

Tecfidera

Testosterone

Trogarzo

Trokendi

Tygacil

Tymlos

Valcyte

Vecamyl

Venofer

Veregen

Vfend

Vibativ

Viberzi

Vimizim

Vivitrol

Xenazine

Xermelo

Xifaxan

Xopenex

Yescarta

Zolgensma  

Zyprexa

Zyvox

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: RX8840