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.

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


Group: RX8840