Contact us at 1-833-FCC-PLAN | Contact Us
Florida Community Care uses the Agency for Health Care Administration (AHCA) Preferred Drug List (PDL). To determine which drugs have limitations or require prior authorization, please review the PDL, Summary of Drug Limitations, and Drug Criteria pages. Use the links below to find more information.
If a medication is not covered or has a restriction such as a prior authorization, step therapy, age limitation, or quantity limit that needs additional review, please complete the appropriate PA request form on the AHCA website or by following this link.
ALL fields must be completed before faxing.
Please fax the completed form to CVS CAREMARK at 1-866-255-7569.
For more information on pharmacy benefits available to Florida Community Care members, click here.
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Samsca_Criteria_a11y.pdf
application/pdfSamsca_Criteria_a11y.pdf Open Download Copy Link 708.75 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Samsca_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSamsca_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 243.99 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sancuso_Criteria_a11y.pdf
application/pdfSancuso_Criteria_a11y.pdf Open Download Copy Link 539.39 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sancuso_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSancuso_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 240.07 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Saphnelo_Criteria_a11y.pdf
application/pdfSaphnelo_Criteria_a11y.pdf Open Download Copy Link 428.75 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Saphnelo_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSaphnelo_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 232.98 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Saphris_Criteria_a11y.pdf
application/pdfSaphris_Criteria_a11y.pdf Open Download Copy Link 461.85 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Saphris_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSaphris_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 247.18 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sedative_Hypnotic_Criteria_a11y.pdf
application/pdfSedative_Hypnotic_Criteria_a11y.pdf Open Download Copy Link 570.2 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sedative_Hypnotic_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSedative_Hypnotic_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 271 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Selzentry_Form_a11y.pdf
application/pdfSelzentry_Form_a11y.pdf Open Download Copy Link 1.34 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Selzentry_Form_a11y_PAC_UA_Report.pdf
application/pdfSelzentry_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 285.43 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sensipar_Criteria_a11y.pdf
application/pdfSensipar_Criteria_a11y.pdf Open Download Copy Link 578.59 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sensipar_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSensipar_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 249.05 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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SEROSTIM_PA_Form_a11y.pdf
application/pdfSEROSTIM_PA_Form_a11y.pdf Open Download Copy Link 1.54 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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SEROSTIM_PA_Form_a11y_PAC_UA_Report.pdf
application/pdfSEROSTIM_PA_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 310.45 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sirturo_Criteria_a11y.pdf
application/pdfSirturo_Criteria_a11y.pdf Open Download Copy Link 387.44 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sirturo_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSirturo_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 228.1 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Soliris_Criteria_a11y.pdf
application/pdfSoliris_Criteria_a11y.pdf Open Download Copy Link 401.38 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Soliris_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSoliris_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 270.39 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Soma_Form_a11y.pdf
application/pdfSoma_Form_a11y.pdf Open Download Copy Link 1.68 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Soma_Form_a11y_PAC_UA_Report.pdf
application/pdfSoma_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 296.92 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spinraza_Criteria_a11y.pdf
application/pdfSpinraza_Criteria_a11y.pdf Open Download Copy Link 501.82 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spinraza_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSpinraza_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 266.42 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spinraza_Form_a11y.pdf
application/pdfSpinraza_Form_a11y.pdf Open Download Copy Link 2.25 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spinraza_Form_a11y_PAC_UA_Report.pdf
application/pdfSpinraza_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 305.71 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spravato_Criteria_a11y.pdf
application/pdfSpravato_Criteria_a11y.pdf Open Download Copy Link 450.06 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Spravato_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSpravato_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 263.73 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Stimulant_Less_Than_6_Yrs_Form_a11y.pdf
application/pdfStimulant_Less_Than_6_Yrs_Form_a11y.pdf Open Download Copy Link 2.22 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Stimulant_Less_Than_6_Yrs_Form_a11y_PAC_UA_Report.pdf
application/pdfStimulant_Less_Than_6_Yrs_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 315.26 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sunosi_Criteria_a11y.pdf
application/pdfSunosi_Criteria_a11y.pdf Open Download Copy Link 395.04 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Sunosi_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSunosi_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 259.95 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Supprelin_LA_Criteria_a11y.pdf
application/pdfSupprelin_LA_Criteria_a11y.pdf Open Download Copy Link 397.27 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Supprelin_LA_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSupprelin_LA_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 262.01 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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SUPPRELIN_LA_FORM_a11y.pdf
application/pdfSUPPRELIN_LA_FORM_a11y.pdf Open Download Copy Link 1.43 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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SUPPRELIN_LA_FORM_a11y_PAC_UA_Report.pdf
application/pdfSUPPRELIN_LA_FORM_a11y_PAC_UA_Report.pdf Open Download Copy Link 282.19 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Symdeko_Criteria_a11y.pdf
application/pdfSymdeko_Criteria_a11y.pdf Open Download Copy Link 509.16 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Symdeko_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSymdeko_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 264.17 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_All_Florida_Regions_Combined_Form_a11y.pdf
application/pdfSynagis_All_Florida_Regions_Combined_Form_a11y.pdf Open Download Copy Link 1.68 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_All_Florida_Regions_Combined_Form_a11y_PAC_UA_Report.pdf
application/pdfSynagis_All_Florida_Regions_Combined_Form_a11y_PAC_UA_Report.pdf Open Download Copy Link 293.66 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_Criteria_a11y.pdf
application/pdfSynagis_Criteria_a11y.pdf Open Download Copy Link 549.53 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSynagis_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 243.04 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_Weight_a11y.pdf
application/pdfSynagis_Weight_a11y.pdf Open Download Copy Link 1.38 MB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synagis_Weight_a11y_PAC_UA_Report.pdf
application/pdfSynagis_Weight_a11y_PAC_UA_Report.pdf Open Download Copy Link 290.99 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synribo_Criteria_a11y.pdf
application/pdfSynribo_Criteria_a11y.pdf Open Download Copy Link 582.89 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Synribo_Criteria_a11y_PAC_UA_Report.pdf
application/pdfSynribo_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 237.25 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Takhzyro_Criteria_a11y.pdf
application/pdfTakhzyro_Criteria_a11y.pdf Open Download Copy Link 617.27 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Takhzyro_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTakhzyro_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 218.88 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tavneos_Criteria_a11y.pdf
application/pdfTavneos_Criteria_a11y.pdf Open Download Copy Link 427.62 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tavneos_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTavneos_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 239.44 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tecartus_Criteria_a11y.pdf
application/pdfTecartus_Criteria_a11y.pdf Open Download Copy Link 452.13 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tecartus_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTecartus_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 233.37 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tepezza_Criteria_a11y.pdf
application/pdfTepezza_Criteria_a11y.pdf Open Download Copy Link 449.68 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tepezza_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTepezza_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 247.25 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Testosterone_Criteria_a11y.pdf
application/pdfTestosterone_Criteria_a11y.pdf Open Download Copy Link 635.8 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Testosterone_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTestosterone_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 259.2 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Thrombopoiesis_Stimulating_Agents_Criteria_a11y.pdf
application/pdfThrombopoiesis_Stimulating_Agents_Criteria_a11y.pdf Open Download Copy Link 475.11 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Thrombopoiesis_Stimulating_Agents_Criteria_a11y_PAC_UA_Report.pdf
application/pdfThrombopoiesis_Stimulating_Agents_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 263.66 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Trikafta_Criteria_a11y.pdf
application/pdfTrikafta_Criteria_a11y.pdf Open Download Copy Link 532.86 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Trikafta_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTrikafta_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 270.43 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Trudhesa_Criteria_a11y.pdf
application/pdfTrudhesa_Criteria_a11y.pdf Open Download Copy Link 403.11 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Trudhesa_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTrudhesa_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 231.25 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tygacil_Criteria_a11y.pdf
application/pdfTygacil_Criteria_a11y.pdf Open Download Copy Link 394.38 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tygacil_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTygacil_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 270.49 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tymlos_Criteria_a11y.pdf
application/pdfTymlos_Criteria_a11y.pdf Open Download Copy Link 443.92 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Tymlos_Criteria_a11y_PAC_UA_Report.pdf
application/pdfTymlos_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 256.3 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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ULTOMIRIS_Criteria_a11y.pdf
application/pdfULTOMIRIS_Criteria_a11y.pdf Open Download Copy Link 617.95 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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ULTOMIRIS_Criteria_a11y_PAC_UA_Report.pdf
application/pdfULTOMIRIS_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 256.98 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Uplizna_Criteria_a11y.pdf
application/pdfUplizna_Criteria_a11y.pdf Open Download Copy Link 483.86 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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Uplizna_Criteria_a11y_PAC_UA_Report.pdf
application/pdfUplizna_Criteria_a11y_PAC_UA_Report.pdf Open Download Copy Link 269.08 KB 2023-12-20 December 20, 2023 2022-10-28 October 28, 2022 |
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