CurrentFlorida BluePolicy N/A

Drugs Not Covered (Florida Blue pharmacy list)

List of brand-name and other prescription medications that Florida Blue excludes from coverage under its pharmacy benefits; affects providers, pharmacists, and members when prescribing or dispensing medications.

Policy Summary

PayerFlorida Blue

PolicyDrugs Not Covered (Florida Blue pharmacy list)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify member benefit documentation and check the New to Market Drug list before prescribing or dispensing to confirm coverage status.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

hundredsmedications listed as Not Covered

appliesnew-to-market rule

Appendix Aexcluded prenatal vitamins

Drugs Not Covered — Coverage Criteria

Not Covered — Drugs explicitly listed as Not Covered

Drugs explicitly listed below are Not Covered

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Newly Marketed Drugs

Newly marketed drugs policy

New-to-Market Review: Newly marketed prescription medications may not be covered until reviewed by the Pharmacy & Therapeutics Committee to determine whether the medication will be covered and, if covered, which tier applies based on safety, efficacy and availability of other products in the class

Reference payer's New to Market Drug list; verify member benefit documentation and prior authorization requirements before dispensing.

This exclusion list identifies specific brand and product-level prescription medications that are Not Covered under Florida Blue’s pharmacy benefits. It does not function as a clinical guideline; instead it notifies prescribers, pharmacists, and billing staff which named products are subject to denial when submitted to the pharmacy benefit.

Drugs that are FDA-approved for weight loss, cosmetic use, or lifestyle modification are explicitly outside the scope of this list and are not covered by the member’s policy unless the member has separately purchased coverage for those products. Newly marketed prescription medications may also be withheld from coverage pending review by the Pharmacy & Therapeutics Committee to determine coverage and tier placement; verify the payer’s New to Market Drug list and member benefit documentation before dispensing.

Provider Actions and Operational Guidance

Prior Authorization

New-to-Market Review — Coverage May Be Delayed

Newly marketed medications may not be covered immediately. The Pharmacy & Therapeutics Committee must review new-to-market drugs to determine coverage and tier placement based on safety, efficacy, and availability of alternatives. Providers should verify whether a drug appears on the payer's New to Market Drug list and confirm prior authorization requirements before prescribing.

Check the payer's New to Market Drug list prior to prescribing
Therapeutic review may delay coverage and tier assignment

Step Therapy

Preferred Alternatives and Step Guidance

Prefer covered generics, biosimilars, or other formulary-preferred alternatives when initiating therapy. Follow any step-therapy requirements in the member's benefit plan; failure to try or document required step therapy may result in a pharmacy claim denial or a requirement to obtain prior authorization.

Use covered generics/biosimilars when available
Adhere to step-therapy and prior authorization rules in the member's benefit plan

Documentation Required

Documentation and Verification Required

Document clinical rationale and medical necessity clearly in the medical record and on any prior authorization requests. Verify member eligibility, benefit coverage, and whether the drug is designated as New to Market before submitting claims to the pharmacy benefit.

Include diagnosis, prior therapies tried, and reason for choosing non-preferred agent in records
Confirm member-specific benefit limits, tiering, and PA requirements at the time of prescribing

Denial Risk

Coverage Denial Risk for Listed Drugs

Drugs listed as newly marketed or otherwise non-preferred are subject to denial when submitted under the pharmacy benefit if coverage criteria are not met or if the product has not completed Pharmacy & Therapeutics review. Providers should anticipate potential denials and use prior authorization pathways when available.

Listed drugs may be denied at point-of-sale if not covered or if PA is required
Contact the plan for appeal or medical exception guidance if a claim is denied

Policy Background

This document is a formulary exclusion list maintained by the payer to identify specific products that are excluded from coverage. Its purpose is to inform prescribers, pharmacists, and claims processors which named medications are subject to coverage denial at the pharmacy benefit level rather than to provide clinical treatment guidance.

Separate from clinical guidance, the list also explains process distinctions: newly marketed drugs may be withheld from coverage until the Pharmacy & Therapeutics Committee reviews safety, efficacy, and class alternatives to determine coverage and tiering, and the New to Market Drug list should be consulted for items under review.

Definitions

inv-09: New to Market Drug list — definition of the payer-maintained list of newly marketed medications

DefinitionA payer-maintained list of newly marketed prescription medications that may be withheld from coverage pending review by the Pharmacy & Therapeutics Committee to determine coverage and formulary tiering.

PurposeTo allow the Pharmacy & Therapeutics Committee to evaluate safety, efficacy, and availability of other products in the class before deciding coverage and tier placement.

ApplicabilityApplies to newly marketed prescription medications; the current items are published on the payer's 'New to Market Drug list.'

Action for ProvidersVerify prior authorization requirements and formulary tiering before dispensing newly marketed medications because they may not be covered until reviewed.

ExclusionsDrugs FDA approved for weight loss, cosmetic use, or lifestyle modification are not included on this list and are not covered unless specifically purchased separately.

OpenPayer

Drugs Not Covered (Florida Blue pharmacy list)

Drugs Not Covered — Coverage Criteria

Provider Actions and Operational Guidance

Policy Background

Definitions

Biosimilar and Branded Products Guidance