Florida Blue Prior Auth Coverage Guidance

What Providers Must Do

Prior Authorization

Prior authorization required for many drugs

Prior authorization is required for many specialty and newly marketed drugs. Newly marketed medications may not be covered until reviewed by the Pharmacy & Therapeutics Committee. Check the member's individual policy for PA program inclusion and coverage determination. Prior Authorization requirements may vary by member plan.

New-to-market drugs may be subject to review before coverage/tiering.
Member-specific plan benefits determine PA applicability — verify the member policy.
Electronic PA (ePA) via CoverMyMeds is preferred; Availity is required for many provider-administered (buy-and-bill) drugs; CVS Specialty Fax Form may be used for prescriptions sent to CVS Specialty.

Prior Authorization

Insulin products without PA

Certain insulin products are preferred and do NOT require prior authorization. When prescribing or dispensing insulin, confirm the product is on the preferred insulin list to avoid unnecessary PA steps.

Preferred insulins that do not require PA: Fiasp; Novolin R; NovoLog; Novolin N; Novolin 70/30; NovoLog 70/30.
Preferred insulin notes appear repeatedly across product entries (e.g., ADMELOG, AFREZZA, LYUMJEV entries reference these preferred products).
Non-preferred insulin products may still require prior authorization depending on the member's plan.

Note

Routing and prior authorization overview

Many specialty drugs list a specific submission channel tied to how the drug is administered and where it is dispensed. Use the indicated portal/form for each drug to avoid processing delays or denials.

If provider-administered (buy-and-bill) in office or outpatient facility: submit via Availity.
If member-/patient-administered and dispensed by Accredo or other specialty pharmacy: CoverMyMeds is commonly used.
If dispensed by CVS Specialty: use the CVS Specialty Fax Form (CVS Specialty will coordinate PA reviews).
Failure to submit via the specified routing may delay or result in denial of the request.

Note

Submission channel per drug

Each drug in the specialty list specifies who administers the product and the required submission/dispensing channel. Follow the per-drug routing: submit via the designated portal/form (CoverMyMeds, CVS Specialty Fax Form, or Availity) and dispense via the indicated pharmacy.

Per-drug entries include three operational fields: member-administered (dispensing pharmacy + submission tool), CVS-dispensed (CVS Specialty Fax Form), and provider-administered (Availity).
Examples: ADMELOG / ADMELOG SOLOSTAR entries reference Accredo/Other Pharmacy (CoverMyMeds) for dispensing and Availity for provider administration; many biologics and infusions list Availity when provider-administered.
For fertility-related products (e.g., CETROTIDE, CLOMID, PREGNYL): if diagnosis is non-fertility related, send the PA request to Availity (routing requirement).

Prior Authorization

Per-drug submission and dispensing instructions

Follow the product-specific submission and dispensing instructions listed for each specialty drug to ensure the PA is routed correctly and processed timely.

Use CoverMyMeds for many member-administered specialty products dispensed by Accredo/Other Pharmacy (ePA preferred).
Use CVS Specialty Fax Form for products dispensed by CVS Specialty; CVS Specialty will coordinate PA reviews for those prescriptions.
Use Availity for provider-administered (infusion/office-administered/buy-and-bill) drugs — this is required for many listed specialty infusions and injectables.
Examples: INFLECTRA/INFLIXIMAB/OCREVUS/KEYTRUDA/LEQVIO and many oncology/immunology infusions specify Availity for provider administration.

Documentation Required

Submit prior authorization via indicated portal/form

Submit prior authorization requests through the portal or form indicated for the specific drug and administration setting. Electronic submission via CoverMyMeds is preferred for ePA; Availity is required for many provider-administered drugs.

Preferred ePA: CoverMyMeds (free service allowing prescribers to submit and check PA status).
Provider-administered/buy-and-bill: submit via Availity.
CVS Specialty-dispensed prescriptions: use the CVS Specialty Fax Form (CVS will coordinate reviews).
If the drug entry lists a specific submission tool (CoverMyMeds, CVS Specialty Fax Form, Availity), use that tool — do not substitute.

Note

Prior authorization routing and exceptions

Routing exceptions and special-case notes are included in the product listings. Pay attention to fertility-related routing and other per-product exceptions to avoid misrouting.

Fertility-related products (e.g., CETROTIDE, CLOMID, PREGNYL): for non-fertility diagnoses, SEND to Availity.
Some starter kits and disease-specific starter packs may include distinct routing instructions (e.g., CIMZIA STARTER KIT, HYRIMOZ starter packs).
New-to-market products may be excluded from coverage until P&T review — check the New-to-Market Drug list.

Note

Prior authorization and submission methods

Submission methods vary by drug and administration route. Use the submission method listed on the drug entry to ensure correct processing.

CoverMyMeds is commonly listed for member-administered products dispensed by Accredo or other specialty pharmacies.
CVS Specialty Fax Form is used when CVS Specialty is the dispensing pharmacy.
Availity is used for many provider-administered products and is specifically noted for numerous infusions and injectables.
Where a drug lists multiple channels, follow the channel that matches the administration and dispensing scenario.

Note

Prior authorization and dispensing routing

Many specialty drugs require submission via the specified channel and will be dispensed by the listed pharmacy. Confirm whether the member or provider is administering and use the corresponding dispensing channel.

Member-administered, dispensed by Accredo/Other Pharmacy: typically submit via CoverMyMeds.
Member-administered, dispensed by CVS Specialty: use CVS Specialty Fax Form.
Provider-administered: submit via Availity (required for many products such as RITUXAN, OCREVUS, KEYTRUDA, INFLECTRA).
Per-drug notes may include preferred biosimilars or alternative preferred agents (see product Notes).

Note

Drug-level dispensing/administration routing

Drug-level routing entries indicate whether the member or provider administers the product and the dispensing source. Use these operational instructions when preparing the PA request.

Operational mapping includes: who administers (Member vs Provider), dispensing pharmacy (Accredo/Other, CVS Specialty), and required submission tool (CoverMyMeds, CVS Specialty Fax, Availity).
Examples across the list: ADMELOG/ADMELOG SOLOSTAR reference Accredo/CoverMyMeds and Availity for provider administration; many biologics list Availity when provider-administered.
Follow the mapping strictly — misrouting the PA (e.g., sending a provider-administered request through CoverMyMeds instead of Availity) may cause delays.

Prior Authorization

Use specified submission channel

Use the specified submission channel for each specialty drug; failure to use the indicated channel may delay or prevent processing of the PA request.

Submission routing requirement: submit via Availity for provider-administered drugs; submit via CoverMyMeds for member-administered drugs dispensed by specialty pharmacies; use CVS Specialty Fax Form for CVS-dispensed specialty prescriptions.
Submission routing mismatch may result in delayed review or denial.
If listed, follow special routing for non-fertility diagnoses (send to Availity).

Note

Routing requirement for non-fertility diagnoses

For certain products (examples: CETROTIDE, CLOMID, PREGNYL, OVIDREL), the listing includes an explicit routing requirement: if the diagnosis is non-fertility related, send the PA to Availity. Observe these routing rules to ensure correct handling.

Routing requirement for non-fertility diagnoses: SEND to Availity for products with fertility-related indications when used for non-fertility diagnoses.
Routing requirement for OVIDREL and similar fertility agents is reiterated across multiple product entries.
Failure to follow the non-fertility routing requirement may lead to processing delays.

Denial Risk

No explicit denial triggers are stated

There are no explicit denial triggers listed in these chunks. However, not following routing/submission channel requirements or failing to verify member plan PA inclusion can increase the risk of denial or delay.

No explicit denial triggers are stated in the product listings provided — routing and submission tool emphasis is the primary operational guidance.
Operational risk: misrouted submissions, missing documentation, or member plan exclusions may lead to denial.
If questions remain after reviewing these instructions and the drug table, contact the number on the back of the member's insurance card for assistance.

Documentation Required

Submission channels and documentation

Submission channels and documentation expectations are summarized for provider convenience. Preserve product-level notes (preferred biosimilars, preferred ESAs, preferred growth hormones) when preparing the PA to select preferred products where applicable.

Preferred biologic/biosimilar guidance appears in product Notes (e.g., Hadlima and Humira preferred over other Humira biosimilars; Procrit/Retacrit preferred over Aranesp/Epogen; Nivestym/Zarxio preferred over Neupogen/Granix).
No step therapy rules are specified in these chunks — if step therapy applies, it will be noted on the member's policy or specific drug entry.
No additional documentation requirements are specified in these chunks beyond following the designated submission channel; include clinical documentation as required by the PA form or portal.

Note

Fertility-related routing note and special notes

Special routing notes and product-specific examples are embedded in the drug list — review Notes for individual drugs such as ENDOMETRIN, FOLLISTIM, OVIDREL and others that have special handling or routing instructions.

For some products (e.g., ENDOMETRIN, FOLLISTIM, OVIDREL), non-fertility uses require Availity submission.
Product-specific notes often call out preferred alternatives or biosimilar preferences — incorporate these when choosing product and completing PA.
When a product lists multiple dispensing options, choose the one that matches the dispensing pharmacy and use the associated submission tool.

Note

Submission tools and dispensing channel

Operational guidance: providers and pharmacies should use the submission tool and dispensing channel specified on the drug entry. Many drugs require CoverMyMeds, CVS Specialty Fax, or Availity depending on dispensing and administration.

Submission tools and dispensing channels: CoverMyMeds (ePA) for many Accredo/Other Pharmacy dispensed products; CVS Specialty Fax Form for CVS-dispensed products; Availity for provider-administered drugs.
For many listed drugs the member or provider must use the specified dispensing channel to coordinate coverage and prior authorization reviews.
Always confirm the correct channel on the specific drug entry prior to submission to reduce processing delays.

Note

Preferred biologic and biosimilar guidance

Preferred product and biosimilar guidance is noted across product entries — when clinically appropriate, select preferred agents to align with plan preferences and reduce barriers to approval.

Preferred biologic guidance: Hadlima and Humira are preferred over other Humira biosimilars in multiple entries.
Preferred ESAs/G-CSF: Procrit and Retacrit are preferred over Aranesp and Epogen; Nivestym and Zarxio are preferred over Neupogen and Granix.
Preferred growth hormone agents: Norditropin, Genotropin and Omnitrope are noted as preferred in the class (e.g., SAIZEN notes).

Definitions and Key Terms

CUVRIOR Notes — Specialty self administered

DefinitionSpecialty self‑administered — refers to specialty medications intended for member (patient) self‑administration at home rather than provider administration in-office or infusion settings.

Typical dispensing pathwayWhen member is self‑administering, specialty pharmacies (Accredo or CVS Specialty) are the usual dispensing channels as indicated per drug entry.

Submission implicationMember‑administered items routed to Accredo/Other Pharmacy use CoverMyMeds; if dispensed by CVS Specialty, use CVS Specialty Fax Form as noted per drug.

Humira biosimilar preference — Hadlima and Humira preferred

Preference statementHadlima and Humira (and Amjevita low‑concentration NDCs) are preferred over other Humira biosimilars for specified Humira starter packs and related entries.

Amjevita noteAmjevita low concentration NDCs (starting with 55513) are referenced as preferred in multiple starter‑pack entries.

Context of applicationPreference appears on Humira/Humira‑biosimilar starter packs and YUFLYMA/YUSIMRY related entries — consult the specific drug line‑item notes for applicability.

Provider will be administering the drug — Provider‑administered

DefinitionProvider‑administered — medication given by a provider in an office, infusion center, or other clinical setting; when indicated, prior authorization submissions for provider‑administered drugs should be routed via Availity.

Submission channelEntries marked 'Provider will be administering the drug' map to Availity for PA submission where specified.

Operational noteProvider‑administered items may not use CoverMyMeds/CVS Specialty routes used for pharmacy dispensing; follow the per‑drug routing instruction in the document.

Member‑administered dispensed by specialty pharmacy — definition

DefinitionMember‑administered (dispensed by specialty pharmacy) — medication intended for patient self‑administration at home, with dispensing performed by a specialty pharmacy (Accredo/Other Pharmacy) or CVS Specialty as specified.

Dispensing pathwaysWhen member is administering and Accredo/Other Pharmacy will dispense, PA/dispensing is routed via CoverMyMeds; when CVS Pharmacy will dispense, use the CVS Specialty Fax Form, per drug note.

Per‑drug instructionCheck the specific drug entry for which specialty pharmacy and submission tool to use (CoverMyMeds vs CVS Specialty Fax Form) — failing to follow the indicated channel may delay processing.

Definitions — (placeholder)

(Reserved)This definition block is intentionally left blank to preserve structure for future definitions or notes.

Operational noteOther definition slots in this section capture provider vs member administration and the corresponding submission/dispensing channels; add content here if additional terms are defined later.

Reference guidanceSee per‑drug entries for routing (CoverMyMeds, CVS Specialty Fax Form, Availity) that map to provider vs member administration.

Biosimilar preference — Amjevita, Hadlima, Humira preferred

Preferred biosimilars (Humira group)Amjevita (low concentration NDCs starting with 55513), Hadlima, and Humira are preferred over other Humira biosimilars for YUFLYMA and related entries.

Where notedPreference appears in YUFLYMA product notes and across multiple Humira biosimilar starter‑pack entries — consult the specific drug line for applicability.

Implementation impactWhen dispensing or submitting PA for Humira biosimilar starter packs, select Amjevita (low‑conc.), Hadlima, or Humira where clinically appropriate to align with stated preference.

Preferred product(s)	Therapeutic class / notes	Policy implication
Procrit, Retacrit	Erythropoiesis‑stimulating agents (ESAs). Notes in the policy indicate Procrit and Retacrit are preferred over Aranesp and Epogen.	Preferred ESA — prescribers should use preferred agents when possible; preference may imply step/formulary placement.
Nivestym, Zarxio	Filgrastim biosimilars (peg‑/filgrastim class). Nivestym and Zarxio are preferred over Neupogen and Granix.	Preferred filgrastim products — use preferred biosimilars prior to non‑preferred alternatives when clinically appropriate.
Amjevita (low concentration), Hadlima, Humira	Adalimumab biosimilars. Policy notes Amjevita (specific low‑concentration NDCs), Hadlima and Humira are preferred over other Humira biosimilars.	Preferred Humira biosimilars — dispensing of preferred biosimilars may affect PA routing and formulary coverage.
Fiasp; Novolin R; NovoLog; Novolin N; Novolin 70/30; NovoLog 70/30	Insulins. Identified as preferred insulin products that do not require prior authorization.	No PA required for these preferred insulins — prescribers may select these to avoid PA where clinically appropriate.

Class / agent group	Preferred agent(s) (policy note)	Interpretation (step/preference)
Erythropoiesis‑stimulating agents (ESAs)	Procrit; Retacrit	Policy lists Procrit and Retacrit as preferred over Aranesp and Epogen, implying a formulary preference or first‑line step before Aranesp/Epogen.
Filgrastim / growth‑factor agents	Nivestym; Zarxio	Preferred over Neupogen and Granix per policy notes; suggests biosimilar preference may be used as a step or dispensing preference.
Adalimumab biosimilars	Amjevita (low‑concentration NDCs); Hadlima; Humira	Policy explicitly prefers these specific adalimumab products over other Humira biosimilars — may affect initial dispensing and PA routing.
Insulins	Fiasp; Novolin R; NovoLog; Novolin N; Novolin 70/30; NovoLog 70/30	Identified as preferred insulins that do not require prior authorization — indicates operational exception rather than clinical step therapy.

OpenPayer

Prior Authorization Program for Prescription Medications (Coverage Criteria)

Coverage Criteria Summary

What Providers Must Do

Policy Background

Definitions and Key Terms

Step Therapy and Preferred Agents

Site of Care and Administration

Biosimilar and Preferred Agent Guidance