Responsible Quantity Program — Pharmacy program updates (Responsible Quantity limits, step therapy, prior authorization, coverage exclusions)
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Updates to Florida Blue's pharmacy programs effective April 1, 2025, including additions to the Responsible Quantity Program (drug-specific dispensing limits) and related step therapy, prior authorization, and coverage exclusion changes for members whose plans include these programs.
Multiple drugs and specific dispensing limits were added to the Responsible Quantity Program effective April 1, 2025.
Certain drugs were added to Step Therapy and Net Results Step Therapy programs (e.g., Aclometasone dipropionate 0.05% ointment and Emrosi 40 mg).
New pharmacy coverage exclusions and Net Results formulary exclusions were listed effective April 1, 2025.
Prior authorization requirements were changed for numerous medications for members in the Prior Authorization Program effective April 1, 2025.
Coverage Criteria Summary
Effective April 1, 2025, Florida Blue's commercial pharmacy plans and the Net Results formulary will implement new pharmacy coverage exclusions. For members enrolled in plans that permit pharmacy coverage exclusions, the payer will no longer cover the specific brand‑name and generic drugs listed in the Responsible Quantity Program exclusion lists; therapeutic or generic alternatives may still be covered. This exclusion for Net Results applies to the separate Net Results formulary and is effective April 1, 2025.
These exclusions apply only to members whose health plans allow pharmacy coverage exclusions; providers should verify member eligibility and benefit design before prescribing or dispensing affected products. Examples from the lists include ophthalmic clobetasol formulations and other named products; the full exclusion lists are published in the Responsible Quantity Program materials effective April 1, 2025.
Provider Actions and Authorization Requirements
Prior authorization required for listed drugs
Prior authorization is required for the long list of medications identified in the policy for members whose plans are part of the Prior Authorization Program, effective April 1, 2025. Submitting a prior authorization is necessary before dispensing these drugs for covered indications for affected members.
- Applies only to members whose plans are part of the Prior Authorization Program.
- Effective April 1, 2025 for the listed medications.
Net Results authorization submissions must use MyPrime.com forms
Net Results authorization requests must be submitted using the Florida Blue Net Results Formulary authorization forms on MyPrime.com; use the Net Results authorization request process when requesting authorization for Net Results-covered medications.
- Use the Florida Blue Net Results Formulary authorization forms available on MyPrime.com.
- Complete and submit the Net Results authorization request form for the drug and indication being requested.
Step therapy program updates and retirements
Step therapy program entries were updated: Emrosi 40 mg capsules were added to oral tetracycline step therapy and Aclometasone dipropionate 0.05% ointment was added to topical corticosteroid step therapy; the Xdemvy step therapy program was retired. Net Results also added Zituvimet and Zituvimet XR to the DPP‑4 inhibitors and combinations program.
- Oral tetracycline step therapy: Emrosi 40 mg added.
- Topical corticosteroid step therapy: Aclometasone dipropionate 0.05% ointment added.
- Xdemvy step therapy: program retired.
- Net Results Step Therapy: Zituvimet and Zituvimet XR added to DPP‑4 inhibitors and combinations.
Provider actions required for members in affected programs
Providers must follow the updated authorization, step therapy, and quantity limit procedures described in this policy when treating members enrolled in the Responsible Quantity, Prior Authorization, or Net Results programs.
- Verify which pharmacy program(s) apply to the member before prescribing or dispensing.
- Submit required Net Results authorization forms via MyPrime.com when applicable.
- Adhere to step therapy requirements and quantity limits effective April 1, 2025.
How to obtain Net Results authorization forms on MyPrime.com
To obtain Net Results authorization request forms, go to MyPrime.com, create a profile or click Forms and select Continue without signing in, then proceed to the Florida Blue Net Results Formulary forms.
- Create a MyPrime.com profile OR: Forms > Continue without signing in.
- Select Florida Blue from the top dropdown and answer No to Medicare status when prompted before accessing Forms.
- On the next page click Forms, then select Florida Blue Net Results Formulary to view forms.
Access Florida Blue Net Results authorization forms (select Florida Blue)
Use the Florida Blue Net Results Formulary authorization request forms on MyPrime.com: select Florida Blue from the top dropdown, answer No to the Medicare status question, then choose the Florida Blue Net Results Formulary form category to access authorization forms.
- Select Florida Blue from the top dropdown menu and No to the Medicare status question.
- On the following page click Forms, then select Florida Blue Net Results Formulary to view available form categories.
Claims may be denied without required prior authorization
Claims for the medications listed under 'Medications Requiring Prior Authorization' may be denied if a required prior authorization is not obtained for members in the Prior Authorization Program.
- Denials apply only to members whose plans are part of the Prior Authorization Program.
- Obtain and document required prior authorization before dispensing to avoid claim denial.
Potential denial or authorization required for quantity limit exceedance
Requests that exceed the Net Results quantity limits listed in the Net Results Quantity Limit Program (effective April 1, 2025) may be denied or require authorization per the Net Results quantity limit program.
- Quantity limits and the specific limits (e.g., Attruby 112 tabs/28 days; Tramadol 75 mg 150 tabs/30 days; Revuforj 110 mg 120 tabs) are listed in the Net Results Quantity Limit Program.
- If prescribing above the listed limit, submit an authorization request per Net Results procedures to avoid denial.
Step Therapy Program Details
| Program | Change / Drug added | Notes |
|---|---|---|
| {"text":"Oral tetracycline step therapy","status":""},{"text":"Emrosi 40 mg capsules added to program","status":""},{"text":"Applies to members in the Responsible Quantity Program; effective Apr 1, 2025","status":""} | ||
| {"text":"Topical Corticosteroid step therapy","status":""},{"text":"Aclometasone dipropionate 0.05% ointment added to program","status":""},{"text":"Applies to members in the Responsible Quantity Program; effective Apr 1, 2025","status":""} | ||
| {"text":"Xdemvy Step therapy","status":""},{"text":"Program retired","status":""},{"text":"Removal from program effective Apr 1, 2025","status":""} | ||
| {"text":"Net Results DPP-4 Inhibitors and Combinations (Net Results Step Therapy)","status":""},{"text":"Zituvimet and Zituvimet XR added","status":""},{"text":"Applies to Net Results formulary; effective Apr 1, 2025","status":""} |
Responsible Quantity Program — Drug-Specific Dispensing Limits
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