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 website.

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys [667KB PDF] Updated 8/4/2014

Adult High Dose Antipsychotic [471KB PDF] New 5/11/2015

Albumin [1.49MB PDF] Updated 8/4/2014

Antidepressants (Age <6 years) [566KB PDF] Updated 12/11/2014

Antipsychotic (Age <6 years of age) [1.34MB PDF] Updated 12/11/2014

Antipsychotic (Age 6 to < 18 years of age) [1.39MB PDF] Updated 12/11/2014

Buprenorphine Agents [544KB PDF] New 1/27/2016

Cytogam [81KB PDF] Updated 6/17/14

Fuzeon [244KB PDF] Updated 6/9/2014

Hepatitis C Agents [2.17MB PDF] Updated 6/13/2016

HIV Diagnosis Verification [1.47MB PDF] Updated 8/4/2014

Human Growth Hormone [489KB PDF] Updated 1/27/2016

Human Growth Hormone for HIV Wasting in Adults (Serostim) [245KB PDF] Updated 6/9/2014

Increlex [2.32MB PDF] Updated 1/18/2017

Miscellaneous Pharmacy Prior Authorization Requests [1.28MB PDF] Updated 5/18/2015

Multi-Source Brand Drugs [1.72MB PDF] Updated 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 [1.71MB PDF] Updated 12/11/2015

Oral Oncology Agents [1.03MB PDF] Updated 8/4/2014

Orfadin [1.32MB PDF] Updated 8/4/2014

Oxycontin ER Oxycontin [1.32MB PDF] Updated 8/4/2014

Panretin [1.72MB PDF] Updated 5/18/2015

Procrit/Aranesp [1.35MB PDF] Updated 8/4/2014

Proleukin [73KB PDF] Updated 6/17/14

Provigil [177KB PDF] Updated 6/2/2016

Selzentry [139KB PDF] Updated 6/9/2014

Serostim [245KB PDF]

Soma [481KB PDF] Updated 6/13/2016

Sovaldi Kick Payment [899KB PDF] New 7/16/2014

Stimulants and Strattera (<6 years of age) [499KB PDF] New 8/18/2015

Supprelin LA [1.45MB PDF] Updated 8/4/2014

Synagis - All Florida Regions Combined [1.32MB PDF] Updated 6/30/2105

Synagis - Weight Change [1.32MB PDF] Updated 8/4/2014

Valcyte [1.30MB PDF] Updated 8/4/2014

Vfend [107KB PDF] Updated 6/17/2014