CurrentFlorida BluePolicy N/A

RxF_Specialty_Table_Prov.pdf

A formulary-like specialty drug table listing numerous drugs with designations for Limited Distribution Drug (LDD), Prior Authorization (PA), and Quantity Limits (QL); indicates these drugs are covered under the medical benefit and that PA/program applicability may vary by plan/provider and some drugs may be available only from specific specialty pharmacies.

Policy Summary

PayerFlorida Blue

PolicyRxF_Specialty_Table_Prov.pdf

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug is designated 'PA', obtain prior authorization per Florida Blue's Prior Authorization Program and member contract; requirements may vary by plan.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this specialty drug table is a listing with annotations (LDD/PA/QL) and the brief indicates has_material_change = false.

~600Listed Specialty Drugs

LDDLDD annotations present

PAPA annotations present

QLQL annotations present

Coverage Summary & Authorization Requirements

General Coverage and Authorization Requirements

Covered under the medical policy when plan and PA requirements are met; specific designations indicate program constraints:

ALL of the following

Coverage: Drug is covered under the medical benefit (medical policy and medical coverage benefits apply).
See provider manual/member contract for benefit details.
Prior Authorization (PA): If listed as PA, prior authorization may be required and requirements may vary by plan.
Providers must consult member contract and Prior Authorization Program for specifics.
Limited Distribution Drug (LDD): If listed as LDD, drug is a Limited Distribution Drug and must be obtained from designated dispensing pharmacy (see 'Limited Distribution Drugs').
LDD indicates limited dispensing locations.
Quantity Limits (QL): If listed as QL, quantity limits apply per the plan's quantity limit policy.
Applicable quantity limits per plan may require prior authorization for quantities exceeding limits.
Provider options
- Self-administered specialty pharmacy dispensing where applicable.
- Provider-administered PADP: Provider-administered drug billing through Provider Administered Drug Program (PADP) if enrolled and drug included in PADP.
  Providers enrolling in PADP must refer to PADP section of provider manual.
Specialty pharmacy coordination: Certain specialty drugs may only be available from a specific specialty pharmacy or pharmacy location; providers should coordinate with Florida Cancer Specialists if unwilling to buy/bill.

This is a specialty drug table indicating drugs are covered under the medical benefit with administrative controls such as LDD (Limited Distribution Drug), PA (Prior Authorization), and QL (Quantity Limit).

Program applicability and PA requirements may vary by plan and provider; providers should consult plan documents and program resources for specifics. The Provider Administered Drug Program (PADP) and the Limited Distribution Drugs resource are referenced for PADP enrollment, buy/bill guidance, and dispensing locations.

Required Provider Actions & Billing Rules

Prior Authorization

Prior Authorization Required for PA-designated drugs

If a drug is designated 'PA', providers must obtain prior authorization according to Florida Blue's Prior Authorization Program and member contract; requirements may vary by plan.

Documentation Required

Limited Distribution Drugs (LDD) sourcing requirement

If a drug is designated 'LDD', providers must obtain the drug from the specified limited distribution pharmacy listed on Florida Blue's 'Limited Distribution Drugs' resource.

Billing Rule

Provider Administered Drug Program (PADP) enrollment

Providers enrolling in PADP and wishing to buy/bill listed drugs must refer to the PADP section of the online provider manual for current included drugs and billing instructions.

Billing Rule

Coordinate with Florida Cancer Specialists when buy/bill not preferred

Providers should coordinate with Florida Cancer Specialists if unwilling to buy/bill certain oncology specialty drugs.

Billing Rule

Quantity Limits for QL-designated drugs

If a drug is annotated 'QL', applicable quantity limits apply per plan policy and must be followed; prior authorization may be required for quantities exceeding limits.

Refer to the PADP section of the online provider manual for PADP enrollment, current included drugs, and buy/bill billing instructions, and consult the Limited Distribution Drugs resource to identify required dispensing pharmacies and plan-specific PA details. LDD means Limited Distribution Drug — the dispensing pharmacy can be found on the Limited Distribution Drugs resource. PA means Prior Authorization is required (requirements may vary by plan). QL means Quantity Limit (limits apply per plan). PADP means Provider Administered Drug Program; providers must be enrolled to buy/bill drugs included in PADP.

Definitions

LDD: Limited Distribution Drug (Dispensing pharmacy can be found on the Limited Distribution Drugs resource).

PA: Prior Authorization required (requirements may vary by plan).

QL: Quantity Limit (limits apply per plan).

PADP: Provider Administered Drug Program; providers must be enrolled to buy/bill drugs included in PADP.

Policy Summary

PayerFlorida Blue

PolicyRxF_Specialty_Table_Prov.pdf

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug is designated 'PA', obtain prior authorization per Florida Blue's Prior Authorization Program and member contract; requirements may vary by plan.

On This Page

Abecma	PA
apomorphine	LDD, PA
Beyfortus
Cimzia prefilled syringe	PA
Abilify Asimtufiit	LDD
Aranesp	PA
Bivigam	LDD, PA
Cinqair	LDD, PA
Abilify Maintena	LDD
Aristada

OpenPayer

RxF_Specialty_Table_Prov.pdf

Coverage Summary & Authorization Requirements

Drug List and Administrative Annotations

Required Provider Actions & Billing Rules

Background

Definitions

Clinical Evidence

Revision History