RxF_Specialty_Table_Prov.pdf
Customize your policy alerts
Sign up for all Florida Blue policy alerts
Know when Florida Blue releases new policies or updates existing guidance.
Monitor payer policy activity
A formulary-like specialty drug table listing numerous drugs with designations for Limited Distribution Drug (LDD), Prior Authorization (PA), and Quantity Limits (QL); indicates these drugs are covered under the medical benefit and that PA/program applicability may vary by plan/provider and some drugs may be available only from specific specialty pharmacies.
No material clinical/coverage changes — this specialty drug table is a listing with annotations (LDD/PA/QL) and the brief indicates has_material_change = false.
Coverage Summary & Authorization Requirements
General Coverage and Authorization Requirements
Covered under the medical policy when plan and PA requirements are met; specific designations indicate program constraints:
ALL of the following
- Coverage: Drug is covered under the medical benefit (medical policy and medical coverage benefits apply).
See provider manual/member contract for benefit details.
- Prior Authorization (PA): If listed as PA, prior authorization may be required and requirements may vary by plan.
Providers must consult member contract and Prior Authorization Program for specifics.
- Limited Distribution Drug (LDD): If listed as LDD, drug is a Limited Distribution Drug and must be obtained from designated dispensing pharmacy (see 'Limited Distribution Drugs').
LDD indicates limited dispensing locations.
- Quantity Limits (QL): If listed as QL, quantity limits apply per the plan's quantity limit policy.
Applicable quantity limits per plan may require prior authorization for quantities exceeding limits.
Provider options
- Self-administered specialty pharmacy dispensing where applicable.
- Provider-administered PADP: Provider-administered drug billing through Provider Administered Drug Program (PADP) if enrolled and drug included in PADP.
Providers enrolling in PADP must refer to PADP section of provider manual.
- Specialty pharmacy coordination: Certain specialty drugs may only be available from a specific specialty pharmacy or pharmacy location; providers should coordinate with Florida Cancer Specialists if unwilling to buy/bill.
This is a specialty drug table indicating drugs are covered under the medical benefit with administrative controls such as LDD (Limited Distribution Drug), PA (Prior Authorization), and QL (Quantity Limit).
Program applicability and PA requirements may vary by plan and provider; providers should consult plan documents and program resources for specifics. The Provider Administered Drug Program (PADP) and the Limited Distribution Drugs resource are referenced for PADP enrollment, buy/bill guidance, and dispensing locations.
Drug List and Administrative Annotations
| Abecma | PA |
| apomorphine | LDD, PA |
| Beyfortus | |
| Cimzia prefilled syringe | PA |
| Abilify Asimtufiit | LDD |
| Aranesp | PA |
| Bivigam | LDD, PA |
| Cinqair | LDD, PA |
| Abilify Maintena | LDD |
| Aristada |
| No codes listed |
Required Provider Actions & Billing Rules
Prior Authorization Required for PA-designated drugs
If a drug is designated 'PA', providers must obtain prior authorization according to Florida Blue's Prior Authorization Program and member contract; requirements may vary by plan.
Limited Distribution Drugs (LDD) sourcing requirement
If a drug is designated 'LDD', providers must obtain the drug from the specified limited distribution pharmacy listed on Florida Blue's 'Limited Distribution Drugs' resource.
Provider Administered Drug Program (PADP) enrollment
Providers enrolling in PADP and wishing to buy/bill listed drugs must refer to the PADP section of the online provider manual for current included drugs and billing instructions.
Coordinate with Florida Cancer Specialists when buy/bill not preferred
Providers should coordinate with Florida Cancer Specialists if unwilling to buy/bill certain oncology specialty drugs.
Quantity Limits for QL-designated drugs
If a drug is annotated 'QL', applicable quantity limits apply per plan policy and must be followed; prior authorization may be required for quantities exceeding limits.
Refer to the PADP section of the online provider manual for PADP enrollment, current included drugs, and buy/bill billing instructions, and consult the Limited Distribution Drugs resource to identify required dispensing pharmacies and plan-specific PA details. LDD means Limited Distribution Drug — the dispensing pharmacy can be found on the Limited Distribution Drugs resource. PA means Prior Authorization is required (requirements may vary by plan). QL means Quantity Limit (limits apply per plan). PADP means Provider Administered Drug Program; providers must be enrolled to buy/bill drugs included in PADP.
Background
This document is a specialty drug table for Florida Blue indicating coverage under the medical benefit and annotation of administrative controls (LDD, PA, QL). It is not an exhaustive coverage list and PA requirements vary by plan. Providers are directed to the PADP section of the provider manual and to limited distribution pharmacy resources for dispensing locations.
Definitions
LDD: Limited Distribution Drug (Dispensing pharmacy can be found on the Limited Distribution Drugs resource).
PA: Prior Authorization required (requirements may vary by plan).
QL: Quantity Limit (limits apply per plan).
PADP: Provider Administered Drug Program; providers must be enrolled to buy/bill drugs included in PADP.
Clinical Evidence
No clinical trials or evidence are provided in this administrative specialty drug table. This file is intended to document coverage designations and program controls (LDD, PA, QL, PADP) and does not include clinical evidence or trial data.
Revision History
Last policy review
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.