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

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