CurrentColorado Rocky Mountain Health PlansPolicy N/A

Florida Medicaid Prior Authorization — Non‑Preferred Diabetic Supply (DSP) form

This document is a prior authorization form and instructions for requesting non‑preferred diabetic supplies (including CGMs) for Florida Medicaid beneficiaries; it governs the PA submission requirements for prescribers and pharmacies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFlorida Medicaid Prior Authorization — Non‑Preferred Diabetic Supply (DSP) form

Policy CodePolicy N/A

Change TypeMinor / administrative

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Florida Medicaid Non‑Preferred Diabetic Supply prior authorization form in full and fax to 1-866-940-7328 or contact Pharmacy PA Call Center 1-855-258-1593.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 YearLength of authorization

1-866-940-7328Fax number

1-855-258-1593PA Call Center

5 yearsDocument retention

Prior Authorization Criteria

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFlorida Medicaid Prior Authorization — Non‑Preferred Diabetic Supply (DSP) form

Policy CodePolicy N/A

Change TypeMinor / administrative

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Florida Medicaid Non‑Preferred Diabetic Supply prior authorization form in full and fax to 1-866-940-7328 or contact Pharmacy PA Call Center 1-855-258-1593.

SourceLink

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Prior authorization will be considered when the form is completed in full with required justification and documentation.

CGM-specific

Is this request for a continuous glucose monitor (CGM)? (Yes/No).
If CGM requested: Is the patient currently receiving insulin? (Yes/No).

Select the patient’s diagnosis: Diabetes Mellitus Type 1; Diabetes Mellitus Type 2; Gestational Diabetes; History of recurring hypoglycemia; or Other.

Provide medical justification explaining why a preferred product cannot be used for this recipient (required).

Attach all required supporting documentation: copies of medical records (e.g., diagnostic evaluations and recent chart notes) and most recent related labs. Provider must retain copies of all documentation for five years.

Provider Submission & Documentation Requirements

Prior Authorization

Submit the completed Florida Medicaid Non‑Preferred Diabetic Supply PA form

Complete and submit the Florida Medicaid Non‑Preferred Diabetic Supply (DSP) prior authorization form in full. An incomplete form may be returned. Fax completed forms to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-855-258-1593.

Documentation Required

Include medical justification and supporting records

Provide medical justification explaining why a preferred product cannot be used and attach all relevant medical records and the most recent related labs. Providers must retain copies of all documentation for five years.

Document why preferred product is unsuitable (medical justification)
Attach copies of diagnostic evaluations and recent chart notes
Attach most recent related laboratory results
Maintain copies of all submitted documentation for five years

Key Definitions

CGM — Continuous glucose monitor (CGM) request indicator

Form fieldIs this request for a continuous glucose monitor (CGM)? (Yes / No)

Follow-up fieldIf yes, indicate whether patient is currently receiving insulin (Yes / No)

Documentation requirementMedical justification required explaining why a preferred product cannot be used when CGM is requested

Record retentionProvider must retain copies of all documentation for five years

Diagnosis options

Required selection optionsDiabetes Mellitus Type 1; Diabetes Mellitus Type 2; Gestational Diabetes; History of recurring hypoglycemia; Other

Form usageSelect the applicable diagnosis option on the prior authorization form

If OtherProvide specification in the 'Other' field on the form

Supporting documentationAttach all relevant medical records and most recent labs to support the diagnosis