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 [PDF 55KB]

Albumin [PDF 61KB]

Antidepressants (Age <6 years) [PDF 111KB]

Antipsychotic (Age <6 years of age) [PDF 99KB]

Antipsychotic (Age 6 to < 18 years of age) [PDF 137KB]

Botox [PDF 52KB]

Cytogam [PDF 75KB]

Fuzeon [PDF 76KB]

HIV Diagnosis Verification [PDF 74KB]

Human Growth Hormone [PDF 111KB]

Human Growth Hormone for HIV Wasting in Adults (Serostim) [PDF 146KB]

Increlex [PDF 73KB]

Criteria for Intravenous Immune Globulin (IVIG). [PDF 120KB] This link provides the latest information regarding the criteria for intravenous immune globulin (IVIG).

Miscellaneous Pharmacy Prior Authorization Requests [PDF 81KB]

Request for Multi-Source Brand Drugs [PDF 81KB]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.

Myobloc [PDF 34KB]

Neupogen/Leukine/Neulasta [PDF 82KB]

Oral Oncology Agents [PDF 69KB]

Orfadin [PDF 74KB]

Oxycontin [PDF 74KB]

Panretin [PDF 29KB]

Procrit/Aranesp [PDF 172KB]

Proleukin [PDF 60KB]

Provigil [PDF 58KB]

Selzentry [PDF 69KB]

SOMA [PDF 146KB]

Suboxone/Subutex [PDF 132KB]

Supprelin LA [PDF 71KB]

Synagis [PDF 97KB]

Synagis - Weight Change

TOBI [PDF 75KB]

Valcyte [PDF 72KB]

VFEND [PDF 97KB]




Reporting Medicaid Fraud