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

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

Antidepressants (Age <6 years) [120KB PDF]

Antipsychotic (Age <6 years of age) [101KB PDF]

Antipsychotic (Age 6 to < 18 years of age) [155KB PDF]

Botox [634KB PDF] Updated 8/4/2014

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

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

Harvoni [1.36MB PDF] New 11/12/2014

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

Human Growth Hormone [209KB PDF] Updated 6/9/2014

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

Increlex [1.47MB PDF] Updated 7/11/2014

Miscellaneous Pharmacy Prior Authorization Requests [1.02MB PDF] Updated 8/4/2014

Request for Multi-Source Brand Drugs [81KB PDF] Updated 7/10/2014 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 [649KB PDF] Updated 8/4/2014

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 [1.30MB PDF] Updated 8/4/2014

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

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

Provigil [1.04MB PDF] Updated 8/4/2014

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

Soma [146KB PDF] Updated 8/4/2014

Sovaldi [1.42MB PDF] Updated 11/12/2014

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

Suboxone/Subutex [260KB PDF] Updated 7/15/2014

Supprelin LA [71KB PDF] Updated 8/4/2014

Synagis - All Florida Regions Combined [97KB PDF] Updated 10/23/2014

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

Tobi [75KB PDF] Updated 8/4/2014

Valcyte [72KB PDF] Updated 8/4/2014

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