Florida Community Plan Pharmacy Prior Authorization Forms

Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys, fentanyl sublingual,

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, lurasidone, perphenazine/amitriptyline,

Albumin,

,

,

,

Leukine, Neupogen, Nyvepria, Fulphila, Fylnetra, Granix, Neulasta, Nivestym, Releuko, Rolvedon, Stimufend, Udenyca, Zarxio, Ziextenzo,

Cytogam,

Aranesp, Epogen, Retacrit, Mircera, Procrit,

Exondys 51,

Fuzeon,

Serostim,

Mavyret, sofosbuvir/velpatasvir, Epclusa, Vosevi, Harvoni, ledipasvir/sofosbuvir, Sovaldi, Viekira Pak, Zepatier, Pegasys, ribavirin ,

,

Genotropin, Norditropin, Humatrope, Nutropin, Omnitrope, Saizen, Skytrofa, Zomacton, Zorbtive, Ngenla, Sogroya,

Increlex,

,

,

NITISINONE, Orfadin, Nityr,

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),

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,

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,

Panretin,

PROLEUKIN,

Selzentry, maraviroc,

Soma, Carisoprodol,

Spinraza, nusinersen,

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,

Supprelin LA, histrelin acetate,

Synagis,

Synagis,

VFEND, Voriconazole,