Pharmacy - Miscellaneous Form
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1FLORIDA MEDICAID
Prior Authorizations
Pharmacy – Miscellaneous
Maximum length of approval = 12 months or less
Note: Form must be complete in full. An incomplete form may be returned.
Recipient’s Medicaid ID #
Date of Birth (MM/DD/YYYY)
__________________________________________
________ / ________ / ______________
Recipient’s Full Name
___________________________________________________________________________________________
Prescriber’s Full Name
Winston R Ortiz ______________________________________________________________________________
Prescriber License # (ME, OS, ARNP, PA)
_______ ME0057742 ______________
Prescriber Phone Number
Prescriber Fax Number
__850___ __878__ - __8121__
__850___ __201__ - __2541__
Drug:
Quantity:
Dosage and Frequency of Dosing:
___________________
_________
___________________
Diagnosis:
___________________________________________________________________________________
Previous Therapy (include drug, dose, and duration):
1.
Date of trial:
__________________________________________
___________________
2.
Date of trial:
__________________________________________
___________________
3.
Date of trial:
__________________________________________
___________________
Reason for Discontinuing Previous Therapy:
Allergic reaction (please specify and submit progress notes to support): _____________________
___________________________________________________________________________________
Contraindication(s) (list conditions): __________________________________________
Drug interaction(s) (please specify): __________________________________________
Therapeutic Failure (please provide lab data, discharge summaries, or progress notes): _____________
Please see attached notes _______________________________________________________________
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
Prescriber’s Signature __________________________________________ Date: __________________________
REQUIRED FOR REVIEW:
Copies of medical records (i.e., diagnostic evaluations and recent chart notes), a copy of the original prescription,
and the most recent copies of related labs.
The provider must retain copies of all documentation for five years.
Fax or mail completed forms to:
For ACHA Use Only
Magellan Medicaid Administration, Inc.
Prior Authorization
DATE: __________________________
NOTIFIED: __________________________
P.O. Box 7082
___________
__________
_________
Tallahassee, FL 32314-7082
APPROVED:
START DATE:
EXPIRATION DATE:
Phone: (877) 553-7481
Fax: (877) 614-1078
DENIED: __________________________ REASON: _________________________________
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