FLORIDA MEDICAID PRIOR AUTHORIZATION
Pharmacy – Miscellaneous
Maximum length of approval = 12 months or less
Note: Form must be completed in full. An incomplete form may be returned.
Mail or Fax Information to:
Magellan Medicaid Administration, Inc.
Prior Authorization
P. O. Box 7082
Tallahassee, FL 32314-7082
Phone: 877-553-7481
Fax: 877-614-1078
Confidentiality Notice: The documents accompanying this transmission contain confidential health
information that is legally privileged. If you are not the intended recipient, you are hereby notified that any
disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly
prohibited. If you have received this information in error, please notify the sender (via return fax)
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other use of this transmission by any party other than the intended recipient is strictly prohibited.
Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY)
/ /
Recipient’s Full Name
Prescriber’s Full Name
Prescriber’s NPI
Prescriber Phone Number Prescriber Fax Number
- - - -
Drug: _______________________ Quantity: _____________ Dosage and Frequency of Dosing: _____________________
Diagnosis: ____________________________________________________________________________________________
Previous Therapy (include drug, dose, and duration):
1. ___________________________________________________________ Date of trial: ____________________
2. ___________________________________________________________ Date of trial: ____________________
Reason for Discontinuing Previous Therapy:
Allergic reaction, contraindication, and/or drug interaction (please specify all and submit progress notes to
support):
__________________________________________________________________________________________
Therapeutic Failure (please provide lab data, discharge summaries, or progress notes):
__________________________________________________________________________________________
Continuation of Therapy:
Patient has a documented positive response to therapy (progress notes required):
__________________________________________________________________________________________
Medical records supporting requested therapy over other preferred medications listed on the Florida Medicaid
Preferred Drug List are required. This list may be found at http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/.
Prescriber’s Signature __________________________________________ Date: _________________________________
REQUIRED FOR REVIEW: All copies of medical records (e.g., diagnostic evaluations and recent chart notes), and the most recent
copies of related labs. The provider must retain copies of all documentation for five years.
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