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Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys, fentanyl sublingual,
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Adult High Dose Antipsychotic (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Abilify, aripiprazole, aripiprazole ODT, chlorpromazine, Clozaril, clozapine, Versacloz, Fanapt, fluphenazine, haloperidol, Latuda, loxapine, molindone, Zyprexa, olanzapine, Zyprexa Zydis, olanzapine ODT, perphenazine, Seroquel, quetiapine, Seroquel XR, quetiapine ER, Risperdal, risperidone, thioridazine, thiothixene, trifluoperazine, Geodon, ziprasidone, Symbyax, olanzapine/fluoxetine, pimozide, prochlorperazine ,
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Albumin (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Albumin,
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Antidepressants [Age < 6 years] (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
,
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Antipsychotic [Age 6 to < 18] (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
,
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Colony Stimulating Factors (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Leukine, Neupogen, Nyvepria, Fulphila, Fylnetra, Granix, Neulasta, Nivestym, Releuko, Rolvedon, Stimufend, Udenyca, Zarxio, Ziextenzo,
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Cytogam (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Cytogam,
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Erythropoeisis Stimulating Agents (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Aranesp, Epogen, Retacrit, Mircerna, Procrit,
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Exondys 51 (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Exondys 51,
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Fuzeon (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Fuzeon,
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Growth Hormone for HIV Wasting in Adults (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Serostim,
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Hepatitis C Agents (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Mavyret, sofosbuvir/velpatasvir, Epclusa, Vosevi, Harvoni, ledipasvir/sofosbuvir, Sovaldi, Viekira Pak, Zepatier, Pegasys, ribavirin ,
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HIV Diagnosis Verification or Prophylaxis For HIV (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
,
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Human Growth Hormone (Florida) Prior Authorization Form - Community Plan
Last Published 10.14.2024
Genotropin, Norditropin, Humatrope, Nutropin, Omnitrope, Saizen, Skytrofa, Zomacton, Zorbtive, Ngenla, Sogroya,
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Increlex (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Increlex,
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Miscellaneous (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
,
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Multi Source Brand Drug (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
,
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Nitisinone (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
NITISINONE, Orfadin, Nityr,
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Non Preferred Diabetic Supply (Florida) Prior Authorization Form - Community Plan
Last Published 10.14.2024
Continuous Glucose Monitors, sensors, transmitters (DEXCOM, ENLITE, EVERSENSE, FREESTYLE LIBRE, GUARDIAN, MINILINK, MINIMED, OMNIPOD, PARADIGM, V-GO) Insulin pump/patch (AMIGO, CEQUR, ILET, INPEN, T:SLIM, TANDEM, TWIIST),
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Opioids (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
MS Contin, morphine ER, fentanyl transdermal, hydrocodone ER, oxymorphone ER, hydromorphone ER, Hysingla ER, Nucynta ER, methadone, Methadose, Oxycontin, oxycodone ER, Xtampza ER, Belbuca, Butrans, buprenorphine patch, Conzip, tramadol ER Apadaz, benzhydrocodone, belladonna alkaloids-opium, opium, Fioricet/Codeine, butalbital/acetaminophen/caffeine/codeine, Ascomp/Codeine, butalbital/aspirin/caffeine/codeine, butorphanol, carisoprodol/aspirin/codeine, codeine, acetaminophen/codeine, Trezix, acetaminophen/caffeine/dihydrocodeine, Xodol, hydrocodone/acetaminophen, Lortab, hydrocodone/ibuprofen, Dilaudid, hydromorphone, levorphanol, meperidine, morphine, oxycodone, Oxaydo, Roxicodone, Nalocet, Percocet, Endocet, Prolate, oxycodone/acetaminophen, oxymorphone, pentazocine/naloxone, Nucynta, Ultram, tramadol, Ultracet, tramadol/acetaminophen, Seglentis, Qdolo, Roxybond,
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Oral Oncology (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
AFINITOR,ALECENSA, ALUNBRIG, AYVAKIT, BALVERSA, BEXAROTENE, BOSULIF, BRAFTOVI, BRUKINSA, CABOMETYX, CALQUENCE, CAPRELSA, COMETRIQ, COPIKTRA, COTELLIC, DAURISMO, EMCYT, ERIVEDGE, ERLEADA, ERLOTINIB, ETOPOSIDE, EVEROLIMUS, EXKIVITY, FARESTON, FOTIVDA, GAVRETO, GILOTRIF, GLEOSTINE, IBRANCE, ICLUSIG, IDHIFA, IMBRUVICA, INLYTA, INQOVI, INREBIC, JAKAFI, JAYPIRCA, KISQALI, KISQALI FEMARA, KOSELUGO, LAPATINIB, LENVIMA, LONSURF, LORBRENA, LYNPARZA, LYSODREN, MEKINIST, MEKTOVI, NERLYNX, NEXAVAR, NILANDRON, NILUTAMIDE, NINLARO, NUBEQA, ODOMZO, ONUREG, ORGOVYX, PEMAZYRE, PIQRAY, PURIXAN, QINLOCK, RETEVMO, ROZLYTREK, RUBRACA, RYDAPT, SCEMBLIX, SORAFENIB, SPRYCEL, STIVARGA, TABLOID, TABRECTA, TAFINLAR, TAGRISSO, TALZENNA, TARCEVA, TARGRETIN, TASIGNA, TAZVERIK, TEPMETKO, THALOMID, TIBSOVO, TOREMIFENE, TRUSELTIQ, TUKYSA, TURALIO, TYKERB, VENCLEXTA, VERZENIO, VITRAKVI, VIZIMPRO, VONJO, WELIREG, XALKORI, XOSPATA, XPOVIO, YONSA, ZEJULA, ZELBORAF, ZOLINZA, ZYDELIG, ZYKADIA,
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Panretin (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Panretin,
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Proleukin (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
PROLEUKIN,
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Selzentry (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Selzentry, maraviroc,
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Soma (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Soma, Carisoprodol,
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Spinraza (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Spinraza, nusinersen,
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Stimulants and Strattera [< 6 years of age] (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Adderall XR, amphetamine-dextroamphetamine ER, Mydayis, Cotempla XR, Daytrana, methylphenidate, Dyanavel XR, Adzenys ER, Amphetamine ER, Focalin XR, dexmethylphenidate ER, methylphenidate ER, Ritalin LA, Aptensio XR, Adhansia XR, Concerta, Relexxii, Quillichew ER, Quillivant XR, Dexedrine, dextroamphetamine ER, Vyvanse, Strattera,
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Supprelin LA (Florida) Prior Authorization Form - Community Plan
Last Published 05.30.2024
Supprelin LA, histrelin acetate,
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Synagis - All Florida Regions Combined (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Synagis,
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Synagis - Weight Change (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
Synagis,
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Vfend (Florida) Prior Authorization Form - Community Plan
Last Published 02.15.2024
VFEND, Voriconazole,