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 (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] Updated 8/4/2014

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

Albumin [1.49MB] Updated 8/4/2014

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

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

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

Buprenorphine Agents [1.9MB] Updated 5/24/2017

Cytogam [589KB] Updated 10/24/2017

Exondys [1.79MB] New 10/24/2017

Fuzeon [244KB] Updated 6/9/2014

Hepatitis C Agents [737KB] Updated 2/22/2017

HIV Diagnosis Verification [598KB] Updated 10/30/2017

Human Growth Hormone [623KB] Updated 3/3/2017

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

Increlex [2.32MB] Updated 1/18/2017

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

Multi-Source Brand Drugs [1.72MB] 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 [618KB] Updated 7/21/2017

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

Orfadin [1.32MB] Updated 8/4/2014

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

Panretin [1.72MB] Updated 5/18/2015

Procrit/Aranesp [1.48MB] Updated 8/11/2017

Proleukin [73KB] Updated 6/17/14

Selzentry [139KB] Updated 6/9/2014

Serostim [245KB]

Soma [481KB] Updated 6/13/2016

Spinraza [1.81MB] New 10/24/2017

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

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

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

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

Valcyte [1.01MB] Updated 3/20/2017

Vfend [107KB] Updated 6/17/2014