Prior Authorization Program for Prescription Medications (Coverage Criteria)
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Defines Florida Blue's prior authorization (PA) program processes for prescription and provider‑administered medications, including submission channels and variability by member plan; applies to providers and pharmacies interacting with Florida Blue members.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
Coverage and PA requirements vary by member plan. Refer to the member's individual policy and medication guide to determine whether a drug is included in the PA program and whether the specific member's plan covers the medication. Prior Authorization requirements may vary and certain drugs may not be covered for some member plans; contact the number on the back of the member's ID card for plan‑specific questions.
Some product entries include routing instructions for non‑fertility related diagnoses. When a note states 'For Non‑Fertility related diagnoses SEND to Availity,' providers should submit requests via Availity for those drugs (examples in the table include CETROTIDE, CHORIONIC GONADOTROPIN, CLOMID/CLOMIPHENE CITRATE, ENDOMETRIN, FOLLISTIM AQ and related entries). Follow the per‑drug routing notes in the table to avoid misrouting.
Certain preferred insulin products do not require prior authorization. The document lists examples including Fiasp, Novolin R, NovoLog, Novolin N, Novolin 70/30, NovoLog 70/30. Requests for insulin products not on the preferred list may still require prior authorization—use the table to confirm PA requirements for non‑preferred insulin products.
Many entries in this section are operational routing instructions describing who administers the drug and which dispensing or submission channel to use (CoverMyMeds, CVS Specialty Fax Form, Accredo/Other Pharmacy, or Availity). These rows do not state explicit coverage exclusions; they are intended to guide submission and dispensing workflows rather than define clinical coverage criteria.
What Providers Must Do
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.
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.
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.
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).
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.
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.
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.
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.
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).
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.
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).
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.
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.
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.
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.
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.
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).
Policy Background
This document enumerates a large number of specialty and pharmacy drugs and provides operational notes about administration, dispensing, and the required prior authorization submission channels. It emphasizes that newly marketed medications undergo review by the Pharmacy Therapeutics Committee before coverage assignment and that providers should use the specified portals (CoverMyMeds preferred, CVS Specialty Fax Form for CVS prescriptions, and Availity for provider‑administered buy‑and‑bill) as indicated per drug entry.
Definitions and Key Terms
Step Therapy and Preferred Agents
| 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. |
Site of Care and Administration
Biosimilar and Preferred Agent Guidance
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