NEW: Prescribers can now send electronic prior authorizations for drugs billed through the fee-for-service delivery system. For more information, an Electronic Prior Authorization information sheet is available on Medicaid’s website.
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 [1.08MB] Updated 8/9/2022
Adult High Dose Antipsychotic [632KB] Updated 1/7/2019
Albumin [1.39MB] Updated 1/7/2019
Antidepressants (Age <6 years) [1.40MB] Updated 10/14/2020
Antipsychotic (Age <6 years of age) [1.41MB] Updated 10/14/2020
Antipsychotic (Age 6 to < 18 years of age) [1.89MB] Updated 3/17/2021
Colony Stimulating Factors [1.33MB] Updated 10/14/2022
Cytogam [1.93MB] Updated 1/7/2019
Erythropoeisis Stimulating Agents Form [991KB] Updated 2/22/2022
Exondys [1.48MB] Updated 1/7/2019
Fuzeon [1.45MB] Updated 1/7/2019
Hepatitis C Agents [240 KB] Updated 10/18/2022
HIV Diagnosis Verification or Prophylaxis of HIV Form [1.34MB] Updated 7/9/2021
Human Growth Hormone [1.26MB] Updated 1/7/2019
Increlex [1.65MB] Updated 1/9/2019
Miscellaneous Pharmacy Prior Authorization Requests [867KB] Updated 2/3/2020
Multi-Source Brand Drugs [1.36MB] Updated 1/9/2019 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.
Nitisinone [1.25MB] Updated 10/13/2020
Opioids [545KB] Updated 10/14/2022
Oral Oncology Agents [1.66MB] Updated 1/9/2019
Panretin [1.66MB] Updated 1/9/2019
Proleukin [1.23MB] Updated 1/11/2019
Selzentry [997KB] Updated 9/13/2021
Serostim [1.59MB] Updated 1/11/2019
Soma [647KB] Updated 1/11/2019
Spinraza [1.43MB] Updated 1/11/2019
Stimulants and Strattera (<6 years of age) [1.43MB] Updated 1/11/2019
Supprelin LA [1.58MB] Updated 1/11/2019
Synagis - All Florida Regions Combined [1.24MB] Updated 10/3/2019
Synagis - Weight Change [1.42MB] Updated 1/11/2019
Vfend [1.57MB] Updated 1/11/2019