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 [55KB PDF]

Albumin [61KB PDF]

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 [52KB PDF]

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

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

HIV Diagnosis Verification [74KB PDF]

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 [81KB PDF]

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 [75KB PDF] Updated 5/15/14

Oral Oncology Agents [59KB PDF]

Orfadin [74KB PDF]

Oxycontin [74KB PDF]

Panretin [29KB PDF]

Procrit/Aranesp [172KB PDF]

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

Provigil [58KB PDF]

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


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

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

Supprelin LA [71KB PDF]

Synagis [97KB PDF]

Synagis - Weight Change [68KB PDF]


Valcyte [72KB PDF]

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