CurrentFlorida BluePolicy N/A

Prior Authorization Form

Defines Florida Blue's prior authorization program processes: newly marketed drug review, medical necessity and step therapy considerations, and preferred submission channels (CoverMyMeds, CVS Specialty Fax Form, Availity) mapped by drug and dispensing/administration scenario (member-administered via Accredo/Other or CVS, provider-administered). This part contains program-level instructions and extensive drug-level routing guidance.

Policy Summary

PayerFlorida Blue

PolicyPrior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative / routing guidance

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionSubmit provider-administered buy-and-bill prior authorization requests through Availity and use CoverMyMeds for member-dispensed Accredo/Other Pharmacy or the CVS Specialty Fax Form when CVS will dispense, per the drug-level mapping.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

manyDrugs listed with submission mapping in this part

~300Drugs listed in part

3Submission channels referenced

severalProvider = Availity entries

Preferred insulin products noted

5Biosimilar preference notes

Policy overview — prior authorization program & submission channels

Scope: Defines Florida Blue's prior authorization program processes: newly marketed medications may be excluded from coverage until reviewed by the Pharmacy & Therapeutics Committee and PA decisions consider medical necessity, step therapy history, and product availability (see member-specific policy). Preferred submission channels are specified by dispensing scenario for many drugs.

Preferred electronic PA channels: Florida Blue prefers CoverMyMeds for electronic prior authorization when Accredo/other pharmacy or member-dispensed specialty drugs are involved; Availity is the portal for provider-administered (buy-and-bill) requests; prescriptions sent to CVS Specialty use the CVS Specialty Fax Form for coordination of PA reviews.

CVS Specialty Fax Form workflow: when CVS Specialty will dispense, submit using the CVS Specialty Fax Form; CVS Specialty will coordinate prior authorization reviews for prescriptions sent to CVS Specialty.

Accredo/CoverMyMeds and Availity workflows and notes: for member-administered specialty prescriptions dispensed by Accredo or other specialty pharmacies use CoverMyMeds where listed; for provider-administered buy-and-bill drugs submit via Availity. If questions remain, call the number on the member's insurance card and refer to the member's individual policy.

Workflow notes for Accredo, CVS Specialty, and Availity: Accredo/other pharmacy — many member-dispensed entries map to CoverMyMeds; CVS Pharmacy dispensing — many entries map to the CVS Specialty Fax Form; provider-administered (office/outpatient) — submit via Availity as indicated.

Effective/Last review dates and part: Effective date: (see member policy); Last review: 2024-04-01. This document is Part 1 of a multi-part mapping and contains the program-level instructions and submission-channel listings for the drugs in this part.

Prior Authorization — quick facts

PayerFlorida Blue

PolicyPrior Authorization Form (Part 5 of multi-part registry)

StatusCURRENT

Last review2024-04-01

Next review

Program scopeDefines PA program processes: newly marketed drugs may be excluded until Pharmacy & Therapeutics review; PA reviews use medical necessity, step therapy history and product availability; preferred submission channels specified by dispensing scenario (CoverMyMeds for Accredo/other, CVS Specialty Fax Form for CVS-dispensed, Availity for provider-administered).

Program-level coverage criteria

Program-level conditions

Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication to determine if the medication will be covered and if so, which tier will apply based on safety, efficacy, and the availability of other products within that class of medications. The current list of newly marketed drugs can be found on our New to Market Drug list.

ALL of the following

Drugs included in our Prior Authorization Program are reviewed based on medical necessity criteria for coverage.
Newly marketed drugs review: coverage may be delayed until Pharmacy & Therapeutics Committee review (see New to Market Drug list).
Program-level consideration
Step therapy: Drugs with step therapy requirements may be covered if a prior health plan paid for the drug; documentation of a paid claim may be required.
step therapy paid-claim exception

Submission channels & routing — drug-level mapping

Intro: For each listed drug, the preferred prior authorization submission channel is specified by dispensing scenario: Member + Accredo/Other Pharmacy, Member + CVS Pharmacy, or Provider-administered (Availity). Each drug entry in this part indicates the preferred PA submission channel depending on the dispensing/administering scenario.

Note: Many entries in this part are partially blank across one or more scenarios; this file is Part 1 of 10 of the full mapping.

Prior Authorization

Submission channel — primary routing

Florida Blue’s primary routing preferences: use CoverMyMeds for electronic prior authorization when Accredo or other (non‑CVS) specialty pharmacies will dispense; use the CVS Specialty Fax Form when CVS Specialty will dispense; submit provider‑administered (buy‑and‑bill) PA requests through Availity.

Use CoverMyMeds for Accredo/Other Pharmacy where listed
Use CVS Specialty Fax Form when CVS Specialty will dispense
Submit provider-administered requests through Availity

Drug routing groups (submission method by dispensing/administration)

Drugs listed in this part of the prior authorization formmixed

D.H.E. 45	D.H.E. 45
DALFAMPRIDINE ER	DALFAMPRIDINE ER
DANAZOL	DANAZOL
DANYELZA	DANYELZA
DARAPRIM	DARAPRIM
DARZALEX (incl. FASPRO)	DARZALEX (incl. FASPRO)
DAURISMO	DAURISMO
DAYBUE	DAYBUE
DAYTRANA	DAYTRANA
DEFITELIO	DEFITELIO

1–10 of 54

1/6

Drugs listed with dispensing/administration routing and formsmixed

FABHALTA	FABHALTA
FABRAZYME	FABRAZYME
FARYDAK	FARYDAK
FASENRA	FASENRA
FASENRA PEN	FASENRA PEN
FEIBA	FEIBA
FENSOLVI	FENSOLVI
FENTANYL (multiple formulations)	FENTANYL (multiple formulations)
FENTORA	FENTORA
FERAHEME	FERAHEME

1–10 of 33

1/4

Routing / Prior Authorization Portal by Drug (extracted entries)mixed

GALAFOLD	GALAFOLD
GAMASTAN	GAMASTAN
GAMIFANT	GAMIFANT
GAMMAGARD (various)	GAMMAGARD (various)
GILOTRIF	GILOTRIF
GIVLAARI	GIVLAARI
GLASSIA	GLASSIA
GLEEVEC	GLEEVEC
GONAL-F	GONAL-F
GONAL-F RFF	GONAL-F RFF

1–10 of 24

1/3

Accredo/Other Pharmacy routing entriesmixed

HETLIOZ / HETLIOZ LQ	HETLIOZ / HETLIOZ LQ
HIZENTRA	HIZENTRA
HULIO	HULIO
HUMALOG (and variants)	HUMALOG (and variants)
HUMALOG JUNIOR KWIKPEN	HUMALOG JUNIOR KWIKPEN
HUMALOG KWIKPEN	HUMALOG KWIKPEN
HUMALOG MIX 50/50 (and KWIKPEN)	HUMALOG MIX 50/50 (and KWIKPEN)
HUMALOG MIX 75/25 (and KWIKPEN)	HUMALOG MIX 75/25 (and KWIKPEN)
HUMALOG TEMPO PEN	HUMALOG TEMPO PEN
HUMATE-P	HUMATE-P

1–10 of 13

1/2

Routing entries (CVS Specialty Fax Form)mixed

HYCAMTIN	HYCAMTIN
HYDROCODONE (various combinations/ER)	HYDROCODONE (various combinations/ER)
HYDROMORPHONE (various)	HYDROMORPHONE (various)
HYFTOR	HYFTOR
HYQVIA	HYQVIA
HYRIMOZ (and starter packs)	HYRIMOZ (and starter packs)
HYSINGLA ER	HYSINGLA ER
IBANDRONATE SODIUM	IBANDRONATE SODIUM
IBRANCE	IBRANCE
IBSRELA	IBSRELA

1–10 of 11

1/2

Provider-administered (Availity) routing entriesmixed

ICATIBANT ACETATE	ICATIBANT ACETATE
ICLUSIG	ICLUSIG
ICOSAPENT ETHYL	ICOSAPENT ETHYL
IDACIO (and starter packages)	IDACIO (and starter packages)
IDELVION	IDELVION
IDHIFA	IDHIFA
ILARIS	ILARIS
ILUMYA	ILUMYA
ILUVIEN	ILUVIEN
IMATINIB MESYLATE	IMATINIB MESYLATE

CoverMyMeds / Accredo- routed drugs (excerpt)mixed

IMBRUVICA	IMBRUVICA
IMCIVREE	IMCIVREE
IMFINZI	IMFINZI
IMIQUIMOD (and pump)	IMIQUIMOD (and pump)
IMITREX (and STATDOSE)	IMITREX (and STATDOSE)
IMJUDO	IMJUDO
IMPAVIDO	IMPAVIDO
INBRIJA	INBRIJA
INCRELEX	INCRELEX
INFLECTRA / INFLIXIMAB	INFLECTRA / INFLIXIMAB

Additional routing entries present in this part (excerpt)mixed

INTUNIV	INTUNIV
IRESSA	IRESSA
ISTURISA	ISTURISA
ITRACONAZOLE	ITRACONAZOLE
IVERMECTIN CRE 1%	IVERMECTIN CRE 1%
IWILFIN	IWILFIN
IXIFI	IXIFI
IXINITY	IXINITY
IZERVAY	IZERVAY
JAKAFI	JAKAFI

1–10 of 20

1/2

Action checklist for providers

Documentation Required

What providers must do

Checklist of required provider actions: document prior plan paid claims when relying on step‑therapy exceptions; refer to the member‑specific policy for PA inclusion; use the preferred portal or form per drug (CoverMyMeds, CVS Specialty Fax Form, Availity); submit provider‑administered buy‑and‑bill requests via Availity; use preferred agents where noted (insulins, growth hormones, biosimilars).

Document prior health plan paid claim for step therapy exceptions
Refer to member-specific policy for PA inclusion
Use preferred portals per drug (CoverMyMeds, CVS Specialty Fax Form, Availity)
Submit provider-administered buy-and-bill via Availity
Use preferred agents where noted (insulins, growth hormones, biosimilars)

Billing Rule

Definitions & abbreviations

Term	Definition
CoverMyMeds
Preferred electronic prior authorization (ePA) service to submit and check PA requests.
Availity
Portal to submit prior authorization requests for provider-administered (buy-and-bill) drugs.
CVS Specialty Fax Form
Fax form used by CVS Specialty to coordinate prior authorization reviews for prescriptions sent to CVS Specialty.
(duplicate) CoverMyMeds
An electronic prior authorization submission pathway referenced for many drugs when Accredo or other pharmacy will dispense.
(duplicate) CVS Specialty Fax Form
Paper/fax submission form used where CVS Pharmacy will dispense specialty medications.
(duplicate) Availity
Provider portal/submission channel for provider-administered drugs or certain routing instructions.
(duplicate) CoverMyMeds
Electronic prior authorization/dispensing routing platform for Accredo or other specialty pharmacies.
(duplicate) CVS Specialty Fax Form
CVS specialty pharmacy fax form used for prior authorization or specialty dispensing requests.
(duplicate) Availity
Provider portal used for submitting prior authorization requests for provider-administered drugs.

Revision history

2024-04-01reviewLatest

Policy review / update

Policy Summary

PayerFlorida Blue

PolicyPrior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative / routing guidance

Effective DateApr 1, 2024

Next Review DateN/A

SourceLink

On This Page

Member-plan variation: Prior Authorization requirements may vary by member plan; certain drugs may not be covered by certain member plans.

member-plan variation

Refer to the member's individual policy and the medication guide for determination of coverage.

policy reference

Member cost-share note: Member cost share may be higher for self-administered specialty drugs not obtained at an in-network specialty pharmacy.

member cost-share note

Provider-administered drugs (buy and bill) for office or outpatient facility settings: submit requests through Availity®.

provider-administered via Availity

For prescriptions sent to CVS Specialty, CVS Specialty will coordinate prior authorization reviews using the CVS Specialty Fax Form.

CVS Specialty Fax Form use

Florida Blue prefers electronic Prior Authorization (ePA) requests through CoverMyMeds - a free ePA service that allows prescribers to submit and check the status of a PA request electronically. Alternatively, standard fax authorization forms are also available.

preference for ePA CoverMyMeds

If you have questions or need further assistance after consulting this table, call the number on the back of the member's insurance card.

call member's card number

Submission channel mapping (drug-level)

When member is administering the drug and Accredo or other specialty pharmacy will dispense: submit PA via CoverMyMeds when indicated by the drug-level mapping.
When member is administering the drug and CVS Pharmacy will be dispensing: follow drug-level mapping; many entries indicate use of CVS Specialty Fax Form when CVS dispenses.
When provider will be administering the drug: submit PA via Availity for buy-and-bill/provider-administered drugs as indicated by drug-level mapping.
Some drug-specific mappings may be blank or vary; always verify the submission channel on the drug-level mapping table before submitting.

Documentation Required

Documentation, exceptions & product preferences

Documentation and exception guidance: step‑therapy exceptions may require documentation of a prior health plan paid claim; refer to the member’s individual policy for whether a drug is included in the PA program. Certain fertility‑related products are noted to be routed to Availity for non‑fertility diagnoses (examples below). Biosimilar and product preferences are explicitly listed for some agents and should be followed where noted.

CETROTIDE
CHORIONIC GONADOTROPIN (HUMAN)
CRINONE
CLOMID / CLOMIPHENE CITRATE
Preferred biosimilars: Amjevita, Hadlima, Humira
Preferred supportive agents: Procrit, Retacrit, Nivestym, Zarxio

The drug-level mapping is long and provided as grouped code lists in the CODING section. Providers should consult the per-drug code groups/tables to find the routing instructions for each dispensing scenario: member-administered (Accredo/Other via CoverMyMeds), member-administered (CVS via CVS Specialty Fax Form), or provider-administered (Availity). Special notes (e.g., fertility-related routing, biosimilar preferences) are included in the per-drug entries.

Preferred-product / billing notes

Preferred-product and billing notes: where the list specifies preferred biosimilars and agents, use those products and the specified NDCs when indicated. Examples: Amjevita, Hadlima and Humira are called out as preferred Humira biosimilars; Procrit and Retacrit are preferred over Aranesp/Epogen; Nivestym and Zarxio are preferred over Neupogen/Granix; for growth hormones the policy names Norditropin, Genotropin and Omnitrope as preferred. Use the specified NDCs when the list references them.

Preferred biosimilars: Amjevita, Hadlima, Humira
Preferred supportive agents: Procrit, Retacrit (preferred over Aranesp/Epogen)
Preferred supportive agents: Nivestym, Zarxio (preferred over Neupogen/Granix)
Preferred growth hormones: Norditropin, Genotropin, Omnitrope
Use specified NDCs where the form lists them

Documentation Required

Fertility-related routing exception

Fertility-related routing exception: the policy lists certain fertility products that should be sent to Availity when the diagnosis is non‑fertility related. Affected products include CETROTIDE, CHORIONIC GONADOTROPIN (HUMAN), CRINONE, and CLOMID/CLOMIPHENE CITRATE. For non‑fertility diagnoses send submissions to Availity as noted.

CETROTIDE
CHORIONIC GONADOTROPIN (HUMAN)
CRINONE
CLOMID / CLOMIPHENE CITRATE
For non-fertility diagnoses send to Availity