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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsFlorida Blue Part B Drug Prior Auth Coverage | Ope…
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    CurrentFlorida BluePolicy N/A

    Part B Drug Prior Authorization Request Form Coverage Criteria

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    Form and instructions for providers to request prior authorization for Medicare Part B drugs from Florida Blue; applies to prescribers submitting requests for coverage or continuation of Part B drugs.

    Policy Summary
    PayerFlorida Blue
    PolicyPart B Drug Prior Authorization Request Form Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionInclude prior Florida Blue approval certificate number on the form when continuing therapy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    72 hrsStandard review timeframe
    24 hrsExpedited review timeframe
    1One-form requirement
    FaxSubmission fax

    Coverage Criteria

    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.

    Initial and Continuation Authorization Requirements

    Covered when ALL of the following are met:

    Required form elements: Form completed with prescriber information, drug administration details, ICD-10 code, diagnosis, and supporting clinical documentation attached

    Missing information may delay or affect determination

    If the member will pick up the drug at a pharmacy rather than receive it in a provider-administered setting, the request must be submitted for Part D coverage rather than Part B. This aligns with the form guidance that pharmacy pickups should be routed through the Part D benefit.

    Coding

    HCPCS / Billing codesHCPCS
    HCPCSHCPCS/HCPCS II code & modifier (place to record on form)
    Diagnosis codesICD-10
    ICD-10ICD-10 Code (diagnosis code to be provided)

    Provider Actions & Requirements

    Prior Authorization

    One form per request

    Use one form per prior authorization request. Submitting multiple requests on a single form may delay review.

    • One-form-per-request: submit a separate completed form for each drug prior authorization request
    Prior Authorization

    Continuation prior approval

    If continuing therapy, include the prior Florida Blue approval certificate number on the form so the request can be processed as a continuation rather than an initial request.

    • Include Prior Florida Blue approval Cert #: (enter certificate number when applicable)
    Billing Rule

    Part D vs Part B coverage note

    If the member will pick up the drug at a retail or specialty pharmacy, submit the request under the Part D benefit rather than Part B. Specialty pharmacy dispensing for participating pharmacy: CVS Caremark; if not using participating specialty pharmacy, coverage may be via Part D.

    • If drug is picked up at a pharmacy → submit for Part D coverage
    • Participating specialty pharmacy: CVS Caremark
    Step Therapy

    Step therapy requirement

    Step therapy is required. Provide a complete medication history listing therapeutic alternatives previously and currently used with start and end dates and outcomes to demonstrate that step-therapy requirements and the definition of medical necessity have been met.

    • List therapeutic alternatives with Dates of Therapy and Reason for Discontinuation
    • Step therapy must be met for coverage determination
    Documentation Required

    Required supporting clinical documentation / Incomplete documentation may delay/deny review

    Attach all pertinent clinical documentation to support the request. Missing information or a lack of prompt response to requests for additional information may delay or result in denial of the review.

    • Attach medical history, progress notes, lab and diagnostic test results
    • Include ICD-10 code and diagnosis on the form
    • Incomplete documentation may delay or deny review
    Prior Authorization

    Prescriber and drug administration details

    Provide full prescriber information and drug administration/dispensing details on the form, including prescriber name, NPI/ID, facility name/address, phone/fax, where the drug will be administered, route, dose, frequency, HCPCS/CPT code and modifier, start date, and whether the provider will buy and bill or the drug will be procured from a specialty pharmacy.

    • Prescriber information: name, ID/NPI, specialty, facility, phone, fax, office contact
    • Drug administration details: where administered, route, dose, frequency, HCPCS/CPT & modifier, start date
    • If administered in a healthcare setting: indicate buy-and-bill vs specialty pharmacy procurement

    Background

    This form supports clinical review to determine medical necessity for Medicare Part B drugs by collecting the clinical and administrative details needed for a coverage decision. Required elements captured on the form include prescriber and facility information, where and how the drug will be administered, start date of therapy, HCPCS billing code and modifier, and documentation of prior approvals when continuing therapy. The form also notes that specialty pharmacy procurement and pharmacy pickup affect benefit routing.

    Definitions

    Specialty pharmacy — definition / note
    DefinitionSpecialty pharmacy — participating specialty pharmacy for this form is CVS Caremark; if not using a participating specialty pharmacy, obtain drug via the Part D benefit.
    Procurement noteIf drug is administered in a healthcare professional setting, indicate whether provider will buy-and-bill or drug will be procured from specialty pharmacy.
    Part D crossoverIf member is picking up drug at a pharmacy, submit the request for Part D coverage rather than Part B.
    Form fieldForm includes a field to record 'Specialty pharmacy' and to document the participating pharmacy when applicable.

    Initial Therapy Criteria

    Initial Therapy

    Initial therapy requests must include medication history and clinical justification:

    Initial request elements: List therapeutic alternatives previously and currently used with start/end dates and outcomes; indicate if medication is for investigational trial use

    Step therapy is required and definition of medical necessity must be met

    Site of care and dispensing details: Provide where drug will be administered (physician office, outpatient hospital, inpatient hospital, home, other) and indicate whether provider will buy-and-bill or drug will be procured from specialty pharmacy

    If member will pick up drug at a pharmacy, submit request for Part D coverage instead of Part B

    Continuation Therapy Criteria

    Continuation Therapy

    For continuation of previously approved therapy:

    Continuation requirements: Include prior Florida Blue approval certificate number and start date of therapy; provide updated clinical information as requested

    Step Therapy Requirements

    Drug name, strength, and dosageDates of therapy (start / end)Reason for discontinuation / outcome
    List each therapeutic alternative previously and currently used for this diagnosis (include brand/generic name, strength, and route)
    Provide start and end dates for each listed therapy
    Document the reason the therapy was discontinued or the clinical outcome (e.g., lack of efficacy, adverse event, intolerance)

    Site of Care

    Note

    Specify site of care and procurement method

    Specify the site where the drug will be administered (physician office, infusion center/outpatient hospital, inpatient hospital, home, or other) and indicate whether the provider will buy-and-bill or the drug will be procured from a specialty pharmacy.

    • Document the specific administration location on the form
    • Indicate buy-and-bill or specialty pharmacy procurement (note: participating specialty pharmacy is CVS Caremark)
    Policy Summary
    PayerFlorida Blue
    PolicyPart B Drug Prior Authorization Request Form Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionInclude prior Florida Blue approval certificate number on the form when continuing therapy.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & RequirementsBackgroundDefinitionsInitial Therapy CriteriaContinuation Therapy CriteriaStep Therapy RequirementsSite of Care