Florida Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

A Florida Medicaid prior authorization form is used by medical professionals to request State Medicaid coverage for a non-preferred drug prescription in the State of Florida. A non-preferred drug is one that is not on the State-approved Preferred Drug List (PDL). The physician must provide justification for their request, as well as attaching any relevant supporting documentation. Once completed, this form should be faxed or sent by mail to the correct directory.

Preferred Drug List – List of pre-approved drugs by the State

Specific Drug Prior Authorization Forms

How to Write

Step 1 – Begin by entering the patient’s Medicaid ID number, date of birth, and full name into the indicated fields.

Step 2 – Next, enter your (the prescriber’s) full name, license number, phone number, and fax number into the appropriate fields.

Step 3 – Below that, enter the name, quantity, dosage, frequency, and relevant diagnosis of the drug that you are requesting coverage for.

Step 4 – If the patient has been prescribed other drugs in treatment of the relevant diagnosis, write the name, dose, and trial duration of each drug as indicated.

Step 5 – Beneath “Reason for Discontinuing Previous Therapy,” enter the allergic reaction(s), contraindication(s), drug interaction(s), and reason for failure of any previous drug trial(s). Relevant medical documentation that supports your justification for not using drugs on the Preferred Drug List (PDL) should be attached to your prior authorization request.

Step 6 – At the bottom of the page, provide your written signature and the date.