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 (850) 412-4166.
These forms are PDF (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 Web site.
Antipsychotic (Age < 18 years of age)
Antipsychotic High Dose (Age 6 to < 18 years of age)
HIV/Hep-B Diagnosis Verification 
12/2/2011
Human Growth Hormone for Adults
Human Growth Hormone for HIV Wasting in Adults (Serostim)
Human Growth Hormone (Non-Preferred) for Children
Criteria for Intravenous Immune Globulin (IVIG). This link provides the latest information regarding the criteria for intravenous immune globulin (IVIG).
Miscellaneous Pharmacy Prior Authorization Requests
Request for Multi-Source Brand Drug - 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.
