Submit this form by faxing it to 1-877-577-9045 for retail pharmacy or 1-844-509-9862 for medical injectables. Allow at least 24 hours for the review process. For any questions, contact 1-844-405-4296.

Ensure you submit the form at least 24 hours before the required authorization date to avoid delays in medication processing for 2024 and 2025.

The purpose of this form is to request prior authorization for medications covered under Florida Medicaid. It ensures that the prescribed medication is medically necessary and meets all program requirements. By completing this form, providers can obtain approval for their prescribed medications and avoid delays in patient care.

• 1. Member Information: Includes details like last name, first name, place of residence, member ID, height, date of birth, weight, and sex.
• 2. Medication Information: Contains fields for drug name/strength, dose, frequency, duration, billing code, diagnosis, and indication.
• 3. Prescriber Information: Includes prescriber's name, address, zip code, phone number, NPI, DEA/license number, and contact information.
• 4. Billing Facility Information: Provides space for billing facility's name, address, zip code, phone number, and NPI/tax ID.
• 5. Pharmacy Information: Requires the pharmacy's name, phone number, fax number, and NPI.

Failing to submit this form may result in delays or denial of medication coverage under Medicaid. It is crucial to complete and submit the form accurately and within the required timeframe.

• Delays in Medication Approval: Without the form, medication authorization cannot be processed, leading to delays.
• Denial of Coverage: Failure to submit the form may result in the denial of medication coverage under Medicaid.

• 1. Medication Authorization: To obtain authorization for prescribed medications.
• 2. Medical Injectables: For authorization requests related to medical injectables.
• 3. Non-Preferred Medications: When prescribing non-preferred medications outside of the FDA labeling.