Medical/Specialty Pharmacy (Rx) Drug Prior Authorization Requirements
Customize your policy alerts
Sign up for all Florida Blue policy alerts
Know when Florida Blue releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Florida Blue requirements and submission routing for prior authorization of Medical/Specialty Pharmacy drugs billed through the medical benefit and lists drugs/HCPCS that require prior authorization for applicable products and settings.
No material clinical or coverage changes in this revision.
Coverage & Authorization Conditions
General coverage conditions tied to prior authorization
Covered when prior authorization is obtained and the member's product covers the drug per medical necessity.
Failure to obtain required prior authorization may result in denial and member/provider financial liability. See product list in source.
Medical necessity may be verified pre-service, concurrently, or post-service depending on product.
Prior Authorization - List Inclusion
Drugs listed require prior authorization as indicated by inclusion on the Medical/Specialty Pharmacy (Rx) Drug List.
Inclusion on the list implies a prior authorization requirement (PADP/CE/SAD flags shown per entry). No additional per‑drug clinical criteria are provided in this excerpt.
Prior Authorization — general
Listed drugs require prior authorization; specific coverage criteria are maintained elsewhere in the policy.
This document segment is a PA drug list; specific clinical medical-necessity criteria for each drug are not present in the excerpt and must be referenced in the drug-specific policy or benefit documents.
Prior Authorization Requirement
Drugs listed require prior authorization.
Specific clinical criteria per drug are not included in these chunks; providers must submit PA requests referencing the listed J-code, drug name, and any PADP/CE flags shown.
The Medical/Specialty Pharmacy (Rx) Drug List is a tool to identify drugs and associated HCPCS/CPT codes that may require prior authorization, but inclusion on the list alone does not guarantee coverage. Verify the member's eligibility and benefits before providing services—coverage is determined by the member's benefit contract and product. The list also does not show prior authorization requirements for medications processed and covered through the member's Pharmacy Benefit Manager (PBM), and it should not be used for BlueCard out-of-area members.
Varithena (polidocanol injectable foam) is listed with a comment that the drug is not separately allowed and is “bundled within”. When Varithena appears under an unclassified listing (C9399) or J-code entry with this comment, it indicates the product is not separately reimbursable and is paid as part of another bundled service rather than as a discrete drug line item.
Some list entries (for example Varithena under J3490) include the note “Drug not separately allowed, bundled within.” This wording signals that the drug is not separately reimbursed when billed in combination with the primary procedure or service and should not be billed as a separately payable pharmaceutical in those instances.
Coverage and prior authorization requirements vary by member plan and product. The drug list is informational for PA processing, but benefits must be verified with Eligibility & Benefits (E&B) prior to service because listed drugs may not be covered under every member's medical benefit.
HCPCS / J-Code / CPT Listings
| J90xx | Oncology and biologic injectables group (sample prefix) |
| C90xx | Cellular/product codes prefix |
| J0118 | Sample referenced code |
| J2490 | Sample placeholder |
| J3590 | Unclassified biologic entries (e.g., ACTEMRA SQ, ADALIMUMAB-AACF, etc.) |
| J9118 | ASPARLAS (CALASPARGASE PAGOL) |
| J9119 | LIBTAYO (CEMIPLIMAB) |
| J9144 | DARZALEX FASPRO (DARATUMUMAB & HYALURONIDASE) |
| J9145 | DARZALEX (DARATUMUMAB) |
| J9153 | VYXEOS (DAUNORUBICIN and CYTARABINE) |
| J9155 | FIRMAGON (DEGARELIX) |
| J9171 | DOCEFREZ / TAXOTERE (DOCETAXEL) |
| J9172 | DOCETAXEL |
| J9173 | IMFINZI (DURVALUMAB) |
| J9174 | BEIZRAY (DOCETAXEL) |
| J9300 | Sample placeholder |
| J9999 | Various unclassified entries (see list) |
| Q2053 | TECARTUS |
| J9024 | TECENTRIQ HYBREZA (ATEZOLIZUMAB & HYALURONIDASE) |
| J9025 | VIDAZA (AZACITIDINE) |
| J9026 | IMDELLTRA (TARLATAMAB-DLLE) |
| J9028 | ANKTIVA (NOGAPENDEKIN ALFA INBAKICEPT) |
| J9029 | ADSTILADRIN (NADOFARAGENE FIRADENOVEC) |
| J9036 | BELRAPZO (BENDAMUSTINE HCI) |
| J9038 | NIKTIMVO (AXATILIMAB) |
| J9039 | BLINCYTO (BLINATUMOMAB) |
| J9041 | VELCADE (BORTEZOMIB) |
| J9043 | JEVTANA (CABAZITAXEL) |
What Providers Must Do
Prior Authorization Required
Florida Blue requires prior authorization (PA) for Medical/Specialty Pharmacy drugs and related services when the member’s product or utilization management program specifies PA is required. Claims for listed drugs (including J-/HCPCS, C9399, and unclassified codes) submitted without the required prior authorization may be denied or require manual review; administration/supportive service codes are considered supportive when the drug itself requires PA unless otherwise specified.
- Prior authorization required for drugs listed in the Medical/Specialty Pharmacy Drug List (includes J-codes, HCPCS, C9399 entries and unclassified Rx entries).
- PADP-marked drugs (PADP = x) are managed by Prime Therapeutics Management (Prime MPS) and require submission to Prime per routing guidance.
- Some HCPCS/J-codes are noted as new effective dates (e.g., J3389, J3387, J0013, J1073, J7174, J3402, J9184, J9184, J9184) — verify code changes when preparing requests.
- Failure to obtain PA prior to service may result in denial and financial liability per the member’s contract.
Where to Submit Prior Authorization
Determine the correct Florida Blue or vendor destination before submitting PA requests. Review these items to identify where to submit: specific drug (brand/generic), member product type (e.g., BlueCare HMO, Medicare Advantage, etc.), place of service, rendering entity participation status, and the entity billing the drug.
- Required identification elements: Specific Drug; Member Product Type; Place of Service; Rendering Entity Participation Status; Rendering Entity (Entity Billing Drug).
- Products that commonly require PA are listed (examples: BlueCare HMO, My Blue, Medicare Advantage HMO/PPO, BlueSelect, BlueOptions, BlueChoice, SimplyBlue, Truli). Verify eligibility/benefit prior to services.
Where to Submit — Vendor Routing Examples
Where to submit — routing summary (consolidated): vendor/phone/fax/portal depend on product, PADP status, and whether the provider is CareCentrix-participating. Use the vendor portal or phone/fax indicated below.
- Prime Therapeutics Management (Prime MPS / formerly MRxM/ICORE) provider self-service: https://gatewaypa.com/ (Physician tab) or phone (800) 424-4947 — used for All** PADP drugs not serviced by a CareCentrix contracted provider.
- Submit electronically through Availity or contact Florida Blue via Blue Express (automated phone) for All drugs not included in PADP and not serviced by CareCentrix.
- CareCentrix (CCX) coordinates reviews for Home Health, Home Infusion, or AIS participating providers — Phone (877) 561-9910, Fax (877) 627-6688.
- Prime Therapeutics LLC (PBM) phone/fax listed for Part D/MedAdv and certain U65 plans per the PA routing guidance.
Required Fields and Documentation
Required fields and documentation on a PA request: include drug name (and generic/alternate name), applicable PADP/CE/SAD flags, drug/service date, HCPCS/J-code(s) or unclassified code (C9399/J3490/J3590 etc.), and clear comments supporting the request (clinical rationale, benefit-specific notes). Attach any supporting clinical documentation and note management changes or HCPCS updates.
- Required fields: DRUG NAME; GENERIC/ALTERNATE; PADP indicator; CE/ and SAD** flags (if present); DRUG date; CODE (HCPCS/J-code/C9399); COMMENTS (clinical justification and payer-specific notes).
- Include HCPCS/J-code mapping and any drug-specific payer comments (e.g., infertility benefit review for certain J3490/J0725/S0122 entries).
- Supportive documentation: clinical notes, prior treatment history, indication, and any benefit-verification evidence. Note any HCPCS/J-code effective dates or new code mappings in the COMMENTS section.
Prime MPS Management & List Updates
Prime MPS management notes and list update cadence: drugs marked PADP = x will be managed by Prime Therapeutics (Prime MPS) — several drugs are scheduled to be added to PADP effective 03/01/2026 or other effective dates noted. The Medical/Specialty Pharmacy list is updated semiannually (January & July); newly FDA-approved drugs and new/unclassified HCPCS codes require PA based on the unclassified codes listed until a permanent code is assigned.
- List update cadence: updates added/removed twice yearly (January & July).
- Newly FDA-approved drugs or drugs with unclassified HCPCS/CPT require PA using unclassified codes (e.g., C9399, J3490, J3590) until a permanent HCPCS is assigned.
- Management changes affecting routing: entries noting "Effective 03/01/2026, drug will be added to PADP and managed by Prime MPS" — include this in submission comments to route to Prime when applicable.
Benefit Verification & Program Flags (PADP / CE / SAD)
Benefit verification and program flags: always verify eligibility and benefits before providing services. Many entries include program flags (PADP, CE/, SAD**) that determine the managing entity and whether special program management applies.
- Verify member coverage/benefit (Eligibility & Benefits) prior to service — PA requirement varies by member product.
- Interpret flags: PADP = managed by Prime MPS; CE/ and SAD** provide additional routing or special authority notes; include these flags on requests.
- Denial risk: services (and supportive services) for products that require PA may be denied if authorization is not obtained prior to service.
Coding & Claim Documentation
Claim coding and coding/documentation notes: include the HCPCS/CPT/Unclassified code(s) referenced, and clearly map the drug to the code used for billing. Note new HCPCS/J-codes and effective dates on the request. For unlisted or unclassified drugs, reference the unclassified code (C9399, J3490, J3590, J7999, etc.) and provide the manufacturer/brand and generic name in the COMMENTS.
- Required coding on requests: HCPCS or J-code(s) used on the claim; if unclassified code is used (C9399, J3490, J3590, J9999, etc.), include drug brand and generic name.
- Coding/Documentation note: New HCPCS/J-codes effective 01/01/2026 and other dates are indicated in the list — callers should reference these effective-date comments when completing the PA.
- Benefit-specific documentation: include notes for specialties (e.g., infertility review required for some J3490/J0725/S0122 entries).
Step Therapy (Not Specified)
Step therapy: no specific step therapy rules are specified in this extract. Where step therapy applies it will be documented in the drug table or program-specific criteria — include any step-therapy details or prior step history in the submission if applicable.
- Step therapy rules: not specified in this extract. Providers should include prior medication history if a step-therapy review may be relevant.
- Operational note: when step therapy is required by the member’s benefit, PA criteria or program-specific guidance will define the required prior agents.
Policy Background
This policy governs utilization management for drugs billed to the medical benefit. Many drugs shown on the Medical/Specialty Pharmacy (Rx) Drug List require prior authorization and are subject to medical necessity review before coverage will be approved. Administration and supportive service codes billed with an authorized drug are generally supported by the drug authorization and do not require separate review unless specifically identified. Providers must determine the appropriate submission routing (for example PADP/Prime Therapeutics, CareCentrix for home infusion, PBM vendors, or Availity/Blue Express) based on the specific drug, the member's product, the place of service, and the billing/rendering entity.
Key Terms & Flags
Step Therapy / Management Notes
| Note | Effective date / impact |
|---|---|
| Several drug entries include a comment that they will be added to the Provider Administered Drug Program (PADP) and managed by Prime MPS. | Effective 03/01/2026 — may change prior authorization routing and program management (providers should verify submission destination and program requirements after this date). |
| Examples shown in the list: NULIBRY (J1809) and multiple other entries indicate 'Effective 03/01/2026, drug will be added to PADP and managed by Prime MPS.' | Effective 03/01/2026 — these specific drugs will be subject to PADP/Prime MPS management per the document comments; prior authorization requirements or routing may change accordingly. |
| Additional J-code entries (e.g., J2468 / palonosetron-related entry) include the same PADP/Prime MPS comment in this segment. | Effective 03/01/2026 — plan and vendor management changes noted; providers must confirm where to submit PA requests once management transfers occur. |
Place-of-Service & Submission Routing
Route PA by place of service (home, outpatient, retail/infusion)
Submission routing depends on place of service: home infusion, outpatient facility, or retail/infusion pharmacy — identify the place of service to determine whether to route to CareCentrix, PADP/Prime, PBM, or Availity/Blue Express.
- Home infusion/AIS participating providers: CareCentrix coordination.
- PADP-managed drugs or PADP-listed providers: Prime Therapeutics gateway.
Vendor-specific routing for physician/outpatient-billed drugs
Certain drugs billed by Florida physicians or outpatient facilities are routed to specific vendors; CareCentrix coordinates reviews for home health/home infusion/AIS participating providers per the policy.
- CareCentrix Phone: 877-561-9910; Fax: 877-627-6688 for participating home infusion/AIS providers.
- FEP and certain Part D/MedAdv routing to Prime Therapeutics or PBMs as noted.
Use PADP/CE flags to determine outpatient/infusion routing
PADP and CE flags on entries often indicate outpatient applicability and specialty pharmacy/infusion center management; when these flags are present, route PA and billing consistent with outpatient/infusion site requirements.
- Entries show PADP or CE flags and comments such as 'Effective 03/01/2026, drug will be added to PADP and managed by Prime MPS' for outpatient/administered products.
HCPCS/J-code drugs imply site-specific routing (infusion/clinic/home)
Drugs listed are HCPCS/J-code administered medical-benefit products; site-specific settings (infusion/clinic/home) are implied by HCPCS billing and should be considered when routing PA and billing.
- HCPCS/J-code administration implies medical-benefit setting such as infusion center or clinic; follow site-of-care routing guidance in the policy.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.