CurrentFlorida BluePolicy N/A

Drugs Not Covered (Florida Blue)

A formulary-level list of prescription drugs and specific product presentations that are excluded from coverage under the payer's 'Drugs Not Covered' program; includes an Appendix A listing excluded prenatal vitamins and notes about newly marketed drugs and weight-loss/cosmetic products. Governs which brand products (and some presentations) are not covered unless specifically purchased or otherwise designated.

Policy Summary

PayerFlorida Blue

PolicyDrugs Not Covered (Florida Blue)

Policy CodePolicy N/A

Change TypeClarified

Effective DateOct 1, 2025

Next Review Date

Key ActionProviders must check member benefit documentation to determine inclusion/exclusion in the Drugs Not Covered program and whether specific products are covered under the member's benefit.

POLICY UPDATE CHANGES

Note that drugs FDA approved for weight loss, cosmetic use or lifestyle modification are not covered unless specifically purchased separately.

hundredsNumber of brand/products listed as Not Covered

1Appendix A Prenatal Vitamin List

2025-10-01Effective date

Coverage Summary

If available, a generic version of a listed brand product is covered unless the generic is also listed (for example, Abilify tablets are excluded but aripiprazole tablets are covered unless aripiprazole is separately listed). Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.

Coverage Exclusions / Applicability

Coverage Exclusions / Applicability — Not Covered when ANY of the following apply:

ANY of the following

Drug is a brand/product included on the Florida Blue 'Drugs that are Not Covered' list as shown in this document (examples: Abilify tablets; Absorica capsules; numerous other brand products listed alphabetically).
The policy document includes an extensive alphabetical list of brand products determined Not Covered as of the effective date.
Newly marketed prescription medications that have not yet been reviewed by the Pharmacy & Therapeutics (P&T) Committee are not covered until P&T review determines coverage and formulary tier.
The current list of newly marketed drugs is maintained by the plan and may change pending P&T decisions.
Drugs FDA approved for weight loss, cosmetic use, or lifestyle modification are not covered under the standard policy unless specifically purchased separately or otherwise specified.
These products are excluded from coverage unless specially arranged; check benefit documentation for member-specific applicability.

Generic Exception

Generic Exception — Covered when ALL of the following are met:

ALL of the following

A generic equivalent exists for a listed brand product and the generic is not separately listed on the 'Drugs that are Not Covered' list.
If the generic is listed as Not Covered as well, it is Not Covered; otherwise the generic is covered.

Not Covered - Brand / Product List

Not Covered - Brand/Product ListmixedNot Covered

Abilify tablets
Abrilada injection
Abilify MyCite tablets
Absorica capsules
Acanya gel and pump gel
Absorica LD capsules
Accrufer capsules
Accupril tablets
Aciphex tablets	(authorized generic for Trezix)
Aciphex Sprinkle capsules

1–10 of 116

1/12

Excluded Prenatal Vitamins (Appendix A)mixedNot Covered

Primacare
Relnate DHA
Altrixa OB
Select-OB
Azesco
Select-OB DHA
CitraNatal Assure
Tristart DHA
CitraNatal Bloom
Virt-nate DHA

1–10 of 69

1/7

Provider Actions & Operational Notes

Documentation Required

Check member benefit documentation

Providers must check member benefit documentation to determine inclusion/exclusion in the Drugs Not Covered program and whether specific products are covered under the member's benefit.

Prior Authorization

Newly marketed drugs review

Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication to determine whether it will be covered and, if so, which formulary tier will apply.

Note: Newly marketed prescription medications may be subject to Pharmacy & Therapeutics Committee review and may not be covered or assigned a formulary tier until reviewed.

Operational note (header/notes): Note that drugs FDA approved for weight loss, cosmetic use or lifestyle modification are not covered unless specifically purchased separately. This statement appears in the document header/notes and is a material clarification to the coverage exclusions.

Background & Definitions

Background: This document is a payer-maintained list of brand drugs and specific product presentations excluded from coverage. It notes that generics are covered unless the generic itself is listed, and that newly marketed prescription medications may not be covered until reviewed by the Pharmacy & Therapeutics Committee to determine coverage and tier. Definition: Drugs Not Covered program — a payer program listing brand products and specific presentations excluded from coverage; generics may be covered unless also excluded.

Effective Dates & Metrics

Key Dates & Scope

Effective Date2025-10-01

Last Review2025-10-01

StatusCURRENT

ScopeFormulary-level list of brand products and specific presentations excluded from coverage; includes Appendix A prenatal vitamins and notes on newly marketed drugs and weight-loss/cosmetic exclusions.