Provider Administered Specialty Drugs
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Defines coverage, prior authorization, limited distribution, and program contacts for provider-administered specialty drugs under Florida Blue medical benefits; applies to providers and facilities billing these drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Certain drugs may not be covered by all plans. Coverage determinations depend on the member contract benefit and the PA program; providers should refer to the member contract benefit and the Prior Authorization Program Information and Forms to determine whether a listed drug is covered and whether prior authorization is required. Coverage under the medical benefit applies for provider‑administered drugs when noted, but this list is not all‑inclusive and plan variations may exclude specific drugs.
Provider Actions and Prior Authorization
Prior Authorization (PA) may be required
Many provider-administered specialty drugs listed in this index require Prior Authorization (PA). PA applicability and requirements vary by drug and by plan; providers should refer to the Prior Authorization Program Information and Forms and the member contract benefit for specific PA details.
- PA requirements vary by drug and plan.
- Refer to the Prior Authorization Program Information and Forms for submission details.
Utilization management (QL and step edits)
Quantity limits (QL) and other utilization management controls such as step edits may apply for some drugs. This document does not detail specific step therapy rules; check the drug-specific PA guidance or plan documents for any step edits.
- QL may be indicated for certain drugs (e.g., QL noted for Xolair).
- Specific step therapy rules are not provided in this index — consult PA guidance or plan documents.
Refer to member contract, PA forms, and PADP for documentation
Providers must consult the member contract benefit, the Prior Authorization Program Information and Forms, and the Provider Administered Drug Program (PADP) section of the online provider manual to determine required documentation and coverage.
- Refer to the PADP section for enrollment and dispensing details for provider-administered drugs.
- Use the Prior Authorization Program Information and Forms to determine documentation required for PA requests.
Obtain PA when required to avoid denial
Coverage may be denied if Prior Authorization is not obtained when the drug requires PA. Prior authorization requirements may differ by plan; verify PA status before providing or billing for a specialty drug.
- Failure to obtain PA when required can result in claim denial.
- Confirm PA requirements against the member contract benefit and PA program materials.
Background
This document is an administrative coverage index that lists provider‑administered specialty drugs and indicates their prior authorization (PA) and Limited Distribution Drug (LDD) status where applicable. It does not provide disease‑specific clinical treatment criteria. Providers enrolled in the Provider Administered Drug Program (PADP) should consult the PADP section of the online provider manual for the current list of included drugs. For questions after consulting the table, contact the Provider Contact Center: 1‑800‑727‑2227 or the phone number on the back of the member’s insurance card.
Definitions
Quantity Limits (Examples)
Site of Care and Benefit Applicability
Bill provider‑administered drugs to the medical benefit (site of care)
When a specialty drug is provider‑administered it is covered under the medical benefit (office, infusion center, or hospital outpatient) and should be billed as a medical benefit; some drugs are self‑administered or dispensed through specialty pharmacies and site of care may vary — PADP enrollment may affect dispensing.
- Provider‑administered drugs are billed under the medical benefit (office, infusion center, hospital outpatient).
- Some drugs are self‑administered or limited distribution—check dispensing pharmacy and PADP guidance.
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