Children's Medical Services Network Pharmacy Prior Authorization Forms

In order to obtain copies of prior authorization forms, please click on the name of the drug requiring prior authorization listed below. If you do not see the name of the drug needing prior authorization listed below you will need to select the Miscellaneous Pharmacy Prior Authorization Request form. If you need assistance, call (800) 603-1714.

These forms are (portable document format) files, which require the use of Acrobat Reader software. If you do not have Acrobat Reader, you may download the free software from the Adobe website.

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys [1.37MB]

Adult High Dose Antipsychotic [1.45MB] New 2/17/2017

Albumin [1.34MB]

Antidepressants (Age <6 years) [548KB] Updated 12/15/2014

Antipsychotic (Age <6 years of age) [534KB] Updated 12/15/2014

Antipsychotic (Age 6 to < 18 years of age) [581B] Updated 12/15/2014

Botox [538KB]

Buprenorphine Agents [1.9MB] Updated 5/24/2017

Cytogam [1.40MB]

Fuzeon [1.36MB]

Hepatitis C Agents [1.67MB] Updated 2/22/2017

HIV Diagnosis Verification [1.34MB]

Human Growth Hormone [1.42MB] Updated 3/9/2017

Human Growth Hormone for HIV Wasting in Adults (Serostim) [1.38MB]

Increlex [2.32MB] Updated 1/18/2017

Miscellaneous Pharmacy Prior Authorization Requests [1.32MB]

Request for Multi-Source Brand Drugs [491KB] Update 6/8/2016
This form is to be used if a patient's prescription was not covered because there is a generic, and the prescribing physician believes the patient has had a bad reaction to the generic; or the brand drug is otherwise medically necessary.

Neupogen/Leukine/Neulasta/Granix/Zarxio [613KB] Updated 5/23/2017

Oral Oncology Agents [1.43MB]

Orfadin [1.41MB]

Oxycontin [1.33MB]

Panretin [1.30MB] Updated 4/1/2015

Procrit/Aranesp [1.40MB]

Proleukin [1.35MB]

Provigil [1.35MB]

Selzentry [1.36MB]

Soma [1.69MB] Update 6/13/2016

Sovaldi Kick Payment [469KB] New 5/6/2015

Stimulants and Strattera (<6 years of age) [490KB] New 8/18/2015

Supprelin LA [1.36MB]

Synagis All Florida Regions Combined [1.38MB] Updated 6/30/2015

Synagis - Weight Change [1.51MB]

Valcyte [583KB] Updated 3/20/2017

Vfend [1.37MB]