As a result of a settlement agreement in the Hernandez vs. Medows lawsuit, effective May 14, 2004, Florida Medicaid began providing the services of an Ombudsman to facilitate the timely resolution of claim reimbursement rejections, when the problems cannot be resolved through self-help by the recipient or intervention by the pharmacy or the prescriber.
Information Pamphlets available in English [826KB] and Spanish [931KB], along with pharmacy guidelines [143KB], have been provided to Medicaid pharmacy providers explaining in detail who should receive the pamphlets and what rights a recipient has if a prescription claim is denied by Medicaid, as well as what the recipient's responsibilities are, and what the prescriber's responsibilities are. A toll free number is included in the pamphlets for the recipient to contact an Ombudsman if all conditions are met and the recipient continues to believe the claim should be approved by Medicaid.
In addition to providing the Information Pamphlets, Medicaid pharmacy providers are also required to post in a conspicuous location within each pharmacy both English and Spanish language signs [390KB] which include the Ombudsman's toll free telephone number (1-866-490-1901). The Ombudsman is prepared to handle calls for both fee-for-service Medicaid and Medicaid prepaid health plans.
If a patient's prescription was not covered because there is a generic, and you, as the prescribing physician, believe the patient has had a bad reaction to the generic; OR the brand drug is otherwise medically necessary, you must fill out and submit a "Request for Multi-Source Brand Drug" form, along with supporting documentation of step therapy and/or adverse reaction. THIS FORM CAN ONLY BE SUBMITTED BY A MEDICAID RECIPIENT'S PRESCRIBING PHYSICIAN.
Follow this link to the "Request for Multi-Source Brand Drug" [1.02MB] form. The “Miscellaneous Pharmacy Prior Authorization Request” form will also need to be submitted. Please click on the following link to view that form: Pharmacy Prior Authorization Forms.