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.

CurrentFlorida BluePolicy N/A

ValueScript Rx Medication Guide (Formulary) — Coverage Criteria

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

Receive email alerts as soon as relevant payer policies are published or updated.

Defines the closed formulary, coverage tiers, specialty pharmacy rules, and member guidance for prescription drug coverage under Florida Blue's ValueScript Rx plan; applies to members and providers using the ValueScript formulary.

Policy Summary

PayerFlorida Blue

PolicyValueScript Rx Medication Guide (Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization form when a medication is marked 'PA' to avoid denial and member liability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Closedformulary type

6pharmacy tiers

1‑monthspecialty dispensing

≤12moPA expiry rule

24/7specialty support

Coverage Criteria and General Policy Rules

General coverage conditions

Covered when meeting plan and formulary conditions:

Formulary inclusion: Medication must be listed on the ValueScript medication list (closed formulary) to be covered.

All non-listed medications are not covered.

Generic substitution and brand requests: Generics are covered unless specifically excluded; if a prescriber requests a brand when a generic is available, the member is responsible for the cost difference unless clinical justification is provided and accepted.

Providers may submit documentation to request a waiver of the brand–generic cost difference.

Plan- and tier-specific rules: Coverage, cost sharing, and program applicability (including whether PA, Responsible Steps, or Medical Pharmacy Tier rules apply) depend on the member's specific plan documents and Schedule of Benefits.

Medication tier assignments may change; the medication guide is updated quarterly and Florida Blue may add/remove drugs at any time.

Policy Summary

PayerFlorida Blue

PolicyValueScript Rx Medication Guide (Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization form when a medication is marked 'PA' to avoid denial and member liability.

SourceLink

On This Page

Coverage Rules and Programs

Coverage and access are governed by drug classification, network participation, and administrative programs:

Self-Administered Specialty Drug Coverage: Self-administered specialty medications must be obtained from a participating specialty pharmacy to be covered at in-network cost share; out-of-network purchases are not covered.

Self-administered injectables are identified in the medication list with 'inj' and will not be covered if administered in a physician's office unless noted otherwise.

Provider-Administered Specialty Drug Coverage: Provider‑administered specialty medications are covered under the medical benefit when administered by an in‑network health care provider and may be processed outside the pharmacy benefit.

Medications administered by a health professional may not appear on the pharmacy drug list and may be subject to the Medical Pharmacy Tier Program.

Medical Pharmacy Tier Program: Provider-administered medications may be placed in Low or Standard tiers to reduce member cost share; medications in this program may also require prior authorization.

Check the Medical Pharmacy Low Tier Drug List and plan documents for applicability.

Prior Authorization Program: Medications indicated in the medication list as requiring Prior Authorization (PA) must have a submitted PA form and approved authorization for coverage; without approval the medication is not covered.PA duration ≤ 12 months

Prior Authorizations expire on the earlier of the policy termination date or the period authorized by Florida Blue, not to exceed 12 months.

Responsible Quantity Program: Certain medications have quantity limits (Responsible Quantity Program) based on FDA and manufacturer recommendations; providers may request an override if a larger quantity is medically required.

Quantity limits are indicated in the medication list.

Responsible Steps (Step Therapy) Program: Medications in the Responsible Steps Program require trial of one or more prerequisite covered medications before the listed medication is approved; providers may request PA to override for medical reasons.

Responsible Steps may apply to both pharmacy and certain medical‑administered medications; check the Responsible Steps listings.

Coding, Identifiers, and Administrative Flags

Identifiersmixed

NCPDP: 6013914	Advocate+ Pharmacy Match NCPDP identifier
NPI: 1366292880	Advocate+ Prescriber NPI

Document header/identifiermixed

87768 0625R

header code present on many lines in this excerpt

Quantity-limited vaccine entriesmixedCovered

QL (1 vaccine/90 days)	Quantity limit applied to PNEUMOVAX 23, PREVNAR 20, VAXNEUVANCE
QL (2 vaccines/1 lifetime)	Quantity limit applied to SHINGRIX (zoster recombinant adjuvanted)

Administrative requirement flags for specialty/antineoplastic agentsmixed

PA	Prior Authorization flag
LD	Limited Distribution flag
SP	Specialty designation

Formulary drug entries (sample)NDC | internal

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (1 kit/28 days)
COPIKTRA - duvelisib cap 15 mg, 25 mg	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (60 capsules/30 days)
COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (63 tablets/28 days)

Formulary drug entries (additional)NDC | internal

IMBRUVICA - ibrutinib tab 140 mg, 280 mg, 420 mg	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (30 tablets/30 days)
JAKAFI - ruxolitinib phosphate tab 5 mg ... 25 mg	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (60 tablets/30 days)
LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg	Drug Tier = 5; Specialty = SP; Requirements/Limits = PA, LD, QL (30 capsules/30 days)

Formulary requirement codesmixed

PA	Prior Authorization
LD	Limited Distribution
SP	Specialty
ST	Responsible Steps (Step Therapy)
QL	Quantity Limit (Max Quantity/Time)

Prior Authorization Expiry

Prior Authorization ExpiryPrior authorizations expire on the earlier of the policy termination date or the period authorized by Florida Blue, not to exceed 12 months.

Maximum DurationAuthorization duration will not exceed 12 months for most medications.

Termination RuleIf the policy terminates earlier than the authorized period, the PA expires on the policy termination date.

Quantity limits examples

Example QL — 4/28dQuantity limit example: 4 units per 28 days.

Example QL — 8/28dQuantity limit example: 8 units per 28 days.

Example QL — 24/28dQuantity limit example: 24 units per 28 days.

Example QL — 32/28dQuantity limit example: 32 units per 28 days.

Example QL — 120/30dQuantity limit example: 120 units per 30 days.

Example QL — 240/30dQuantity limit example: 240 units per 30 days.

Repatha limit

REPATHA (prefilled syringe)Quantity Limit: 6 syringes per 28 days.

Requirement FlagsListed with PA and QL indicators (prior authorization and quantity limit may apply).

Coverage NoteCoverage subject to meeting listed Requirements/Limits in the medication list.

Repatha SureClick limit

REPATHA SURECLICK (auto-injector)Quantity Limit: 6 pens per 28 days.

Requirement FlagsListed with PA and QL indicators (prior authorization and quantity limit may apply).

Coverage NoteCoverage subject to meeting listed Requirements/Limits in the medication list.

Vyndamax limit

VYNDAMAX (tafamidis)Quantity Limit: 30 capsules per 30 days.

Requirement FlagsMarked with PA and QL in the medication list; prior authorization and quantity limits may apply.

Coverage NoteCovered under specified requirements; refer to medication line for medical necessity criteria.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization may be required

Certain specialty and provider‑administered medications listed in the medication guide may be subject to prior authorization under the plan. Providers should verify the medication's Requirements/Limits field and submit a PA when the PA indicator is present to avoid coverage denial.

Prior Authorization

Submit Prior Authorization when PA shown

When a medication line shows a prior authorization indicator, the prescribing physician is required to complete and submit a Prior Authorization form so the prescription can be considered for coverage; approvals may be limited to the earlier of the policy termination date or up to 12 months.

Prior Authorization

PA enforces appropriate use before coverage

Prior authorization is used to encourage appropriate, safe, and cost‑effective use of medications; if the PA indicator is present the PA program may apply to the member's benefit and coverage may be approved only after listed criteria are met.

Prior Authorization

PA required for select high‑tier/specialty drugs

Select high‑tier and specialty agents (examples in the formulary include NUZYRA and SIRTURO) are designated with Requirements/Limits = PA and require prior authorization before they will be covered.

NUZYRA (omadacycline) listed among anti‑infectives with PA flags
SIRTURO (bedaquiline) indicated Specialty = SP and Requirements/Limits = PA, LD, QL

Prior Authorization

PA required for specialty antivirals/hepatitis C regimens

Certain high‑cost antivirals and hepatitis C regimens are marked PA (examples include EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) and require prior authorization before coverage.

EPCLUSA — Requirements/Limits = PA, QL (28 tablets/28 days)
MAVYRET — Requirements/Limits = PA, QL (84 tablets/28 days)
VOSEVI — Requirements/Limits = PA, QL (28 tablets/28 days)

Prior Authorization

PA required for listed agents (examples)

Listed agents such as VOSEVI, COARTEM, IMPAVIDO, SIVEXTRO, and selected strengths of XIFAXAN carry a PA requirement and must have prior authorization before dispensing.

VOSEVI — PA, QL (28 tablets/28 days)
COARTEM — Requirements/Limits = PA
IMPAVIDO — Requirements/Limits = PA
SIVEXTRO — Requirements/Limits = PA, QL (6 tablets/30 days)
XIFAXAN — Requirements/Limits = PA, QL (strength‑dependent)

Prior Authorization

PA required for many specialty agents

Many specialty products including immune globulins, antineoplastics, and oral oncology agents are designated 'PA' (and often 'SP'/'LD') and require prior authorization prior to coverage.

Immune globulins (e.g., GAMMAGARD, GAMUNEX‑C, HIZENTRA) — Requirements/Limits = PA (and LD where noted)
Numerous antineoplastic agents list PA in Requirements/Limits

Documentation Required

PA, LD, and QL may apply per product

Several drugs in the formulary are shown with multiple administrative flags; when PA, LD, and QL appear on a product line, providers must meet prior authorization requirements and adhere to limited distribution and quantity limits as indicated.

Prior Authorization

Obtain PA for listed specialty/oncology agents

This segment of the formulary contains many specialty and oncology agents that are flagged PA; providers must obtain authorization for these products before coverage will be processed.

Prior Authorization

PA required for select oncology agents

Multiple oncology products (e.g., XPOVIO, XTANDI, ZEJULA, YONSA) list Prior Authorization in their Requirements/Limits and require PA before coverage.

XPOVIO — Requirements/Limits = PA, LD, QL
XTANDI — Requirements/Limits = PA, LD, QL
ZEJULA / YONSA — Requirements/Limits = PA, LD, QL

Prior Authorization

PA required for selected antidiabetic/GLP‑1 agents

Selected antidiabetic and GLP‑1 agents are marked with PA in the formulary (examples include MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, and TRIJARDY XR) and require prior authorization prior to coverage.

MOUNJARO — Requirements/Limits = PA, QL (4 pens/28 or 180 days depending on listing)
OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days)
RYBELSUS — Requirements/Limits = PA, QL (varies by strength)

Prior Authorization

PA required for additional listed drugs

Numerous other branded therapies (examples include ORILISSA, OSPHENA and others) are shown with a PA requirement on the drug line and must have prior authorization before benefits apply.

ORILISSA — Requirements/Limits = PA, QL
OSPHENA — Requirements/Limits = PA

Prior Authorization

Prior authorization required where indicated

Certain listed products require prior authorization before coverage; providers must check the Requirements/Limits field and submit PA documentation when 'PA' is indicated.

Note

Condition Care Rx Program — check Schedule of Benefits

The Condition Care Rx Program promotes use of specified, lower‑cost medications for chronic conditions; providers should check the member's Schedule of Benefits to determine program applicability and preferred alternatives.

Step Therapy

Responsible Steps: try prerequisites before coverage

Under the Responsible Steps step‑therapy program, members must try one or more covered alternative medications before the Responsible Steps medication will be covered; providers may request a PA override for medical reasons if prerequisites cannot be used.

Provider may submit prior authorization to request an override for medical reasons
Responsible Steps lists and forms available at Responsible Steps Program Information

Step Therapy

Responsible Steps applies to medical‑administered drugs

For physician‑administered (medical pharmacy) Responsible Steps drugs, members must trial the prerequisite drug(s) before coverage of the higher‑cost medication; the provider can request a prior authorization override for medical reasons.

Step Therapy

Responsible Steps (ST) applies to select antidiabetics

Step therapy applies to various antidiabetic agents and combinations (Responsible Steps/ST indicated); examples include FARXIGA, GLYXAMBI, JANUMET, JANUMET XR, JANUVIA and related products which are marked ST and have QL where noted.

FARXIGA — Requirements/Limits = ST, QL (30 tablets/30 days)
JANUMET / JANUMET XR — Requirements/Limits = ST, QL
JANUVIA — Requirements/Limits = ST, QL (30 tablets/30 days)

Note

ST = Responsible Steps (step therapy indicator)

The 'ST' label in the Requirements/Limits key denotes Responsible Steps (step therapy); when 'ST' appears on a product line the step‑therapy program may apply and prerequisite requirements must be met.

Step Therapy

Follow ST program when applicable; request PA for overrides

Prescribers must follow the Responsible Steps (ST) program when a product is marked 'ST' on the medication list; if prerequisites cannot be used, submit prior authorization for an override.

Check Responsible Steps list for required prerequisite agents
Submit PA to request override for medical reasons

Documentation Required

Provide documentation when brand required over generic

If a prescriber requires a brand‑name product when an AB‑rated generic is available, the prescriber must provide supporting documentation to justify the brand to avoid the member being responsible for the cost difference.

Supporting documentation required to request exception to the cost difference

Prior Authorization

Complete and submit the Prior Authorization form

Providers are required to complete and submit the Prior Authorization form for coverage determinations when a drug's Requirements/Limits field indicates PA; the decision will be communicated to the member and provider.

If PA is denied, the member may purchase the medication but will pay full cost and is not entitled to reimbursement

Documentation Required

Submit Coverage Exception Request; note decision timelines

Coverage exceptions (standard or expedited) must be submitted using the Coverage Exception Request Form by the prescriber, member, or designee; standard requests are decided within 72 hours and expedited requests within 24 hours.

Standard exception decision: within 72 hours
Expedited exception decision: within 24 hours

Documentation Required

Documentation and limits for antimycobacterial agents

Specialty antimycobacterial agents (e.g., SIRTURO, pretomanid) are listed with PA and LD flags and have specified QL values that must be adhered to when requesting coverage.

SIRTURO (bedaquiline) — Requirements/Limits = PA, LD, QL (940 tablets/365 days or 188 tablets/365 days depending on strength)
PRETOMANID — Requirements/Limits = LD, QL (182 tablets/365 days)

Prior Authorization

Obtain PA for specialty antiviral agents

Prescribers must obtain prior authorization for the specialty antiviral agents flagged PA in the medication list before dispensing; PA documentation should be submitted per the Prior Authorization Program instructions.

Documentation Required

PA/LD indicate authorization or distribution controls

The formulary key indicates 'PA' and 'LD' denote payer authorization and limited distribution controls; products so marked require submission of authorization documentation and adherence to the specified distribution channel.

Documentation Required

Submit authorization docs and use LD channels for PA/LD products

Products labeled 'PA' require prior authorization documentation and products labeled 'LD' must be sourced through the limited distribution network listed; providers must supply authorization and follow distribution procedures when applicable.

Note

Key: PA, LD, QL definitions

The policy key explains the requirement codes: PA = Prior Authorization; LD = Limited Distribution; QL = Quantity Limit (maximum quantity per time period).

Documentation Required

Supply authorization info for PA/LD/QL drugs

The medication list shows which products carry PA, LD, and QL requirements; providers must meet these requirements and include authorization details when submitting claims for PA‑designated drugs.

Documentation Required

Provide PA documentation and use LD channels as required

Prescribers must provide documentation to satisfy prior authorization when requesting drugs marked 'PA' and must use the specialty or limited distribution channels indicated for drugs marked 'LD'.

Documentation Required

Adhere to formulary requirement tags on drug lines

Formulary entries include requirement tags (PA, ST, QL); when these tags appear the provider must follow the associated program rules or supply required documentation as part of the authorization or claims process.

Documentation Required

LD and PA products require distribution documentation and PA

When a product is designated LD and/or PA, providers must document limited distribution sourcing and submit prior authorization as required; examples in the guide include medications such as Kuvan and SOMAVERT.

KUVAN — Requirements/Limits = PA, LD
SOMAVERT — Requirements/Limits = LD

Billing Rule

Adhere to quantity limits; exceedances require documentation/PA

Many specialty drugs include quantity limits (QL) specified per drug and time period; prescriptions that exceed the stated QL may require supporting documentation or prior authorization for coverage.

Repatha — QL (6 syringes/28 days)
Examples show QL values for numerous products across the formulary

Denial Risk

Non‑formulary medications are not covered

Medications not listed on the ValueScript formulary are not covered; prescribing a non‑formulary medication without an approved exception may result in denial and full member financial responsibility.

Denial Risk

No PA submitted/received → no coverage

If a prior authorization is not requested or received for a PA‑flagged drug, the medication will not be covered and the member will be responsible for the full cost without entitlement to reimbursement.

Denial Risk

PA noncompliance may trigger denial

Failure to meet the prior authorization criteria for drugs that display a PA indicator may result in coverage denial; providers should ensure PA criteria are met before dispensing.

Denial Risk

PA/LD/SP/QL flags may trigger denial if unmet

Drugs marked with PA, LD, SP, or QL indicate utilization management or distribution controls; if those requirements are not met (for example, sourcing via LD or obtaining PA), coverage may be denied.

Denial Risk

PA required for select hepatitis C/antiviral agents

Certain hepatitis C and other specialty antiviral agents (EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) are subject to prior authorization and may be denied if PA is not obtained.

Documentation Required

Follow PA/LD markers on drug lines

Authorization markers (PA, LD) are present next to many drug lines (e.g., COARTEM, VOSEVI, BENZNIDAZOLE) and indicate that payer authorization or limited distribution procedures must be followed to obtain coverage.

Denial Risk

Obtain PA and follow LD channels to avoid denial

Requests for products flagged 'PA' or 'LD' may be denied if prior authorization is not obtained or if distribution constraints are not followed; providers must obtain approval and route orders through the correct channels.

Denial Risk

Claims may be denied without PA

Claims for products with 'PA' in the Requirements/Limits field may be denied without an approved prior authorization; ensure PA is in place before claim submission.

Denial Risk

PA and LD noncompliance risks denial

Drugs listed with PA and/or LD require an approved prior authorization and, for LD products, sourcing through the specified limited distribution channel; failure to comply may result in denial or claim processing failure.

Denial Risk

PA, LD, or QL violations may prompt denial

Requests for medications listed with PA, LD, or exceeding specified QL values may be denied or require prior authorization review; check each product's Requirements/Limits prior to prescribing or dispensing.

Documentation Required

PA/ST/QL on line items require documentation or PA

When a prescription is marked with PA, ST, or QL, prior authorization or evidence of prerequisite therapy and adherence to quantity limits may be required for approval; providers should submit necessary documentation to support the request.

Denial Risk

Exceeding QL or missing PA may cause denial

Requests that exceed quantity limits (e.g., tolvaptan Jynarque 56 tablets/28 days or Samsca listings) or lack required prior authorization may be denied; obtain PA or provide justification when exceeding QL.

Jynarque (tolvaptan) — QL 56 tablets/28 days
Samsca (tolvaptan) — QL examples include 30 tablets/365 days or 60 tablets/30 days

Prior Authorization

Verify PA applicability and obtain authorization

Prior authorization is required for many of the drugs flagged 'PA' in the medication list; providers should verify PA applicability for the patient’s plan and obtain authorization to avoid claim denials.

Definitions and Key Legend

Specialty Pharmacy Medications

DefinitionSpecialty Pharmacy Medications are high-cost injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of the patient's therapy.

DispensingSpecialty drugs are only covered when dispensed from a Specialty Pharmacy (self-administered specialty drugs) or when administered by a provider (provider-administered) under the medical benefit.

Standard SupplySpecialty Drugs are generally dispensed up to a one-month supply unless otherwise specified by manufacturer packaging or FDA dosing requirements.

Pharmacy Tiers

Tier StructureSix tiers: Tier 1 preventive; Tier 2 condition care generic; Tier 3 low-cost generic; Tier 4 condition care brand; Tier 5 high-cost generic/preferred brand; Tier 6 specialty/non-preferred (some specialty drugs may be listed in lower tiers).

Cost-share ImplicationTier assignment determines member cost share as described in the member's Schedule of Benefits.

Tier ChangesMedications may be reassigned between tiers and are reviewed quarterly.

Self-Administered Specialty Medications

DefinitionSelf-Administered Specialty Medications are specialty pharmacy medications intended for patient self-administration (often designated with 'inj' for injectables in the medication list).

Coverage CaveatThese medications may not be covered if administered in a physician's office and must be obtained from a participating specialty pharmacy for in-network coverage; out-of-network coverage is not available if not obtained from a participating specialty pharmacy.

Cost-shareSelf-administered injectables are subject to the Brand or Generic cost share as described in the member's Schedule of Benefits.

Provider-Administered Specialty Medications

DefinitionProvider-Administered Specialty Medications require administration by a physician and are covered under the member's medical benefit.

SourcingThese medications can be obtained from any in‑network health care provider and may be billed to the medical benefit rather than pharmacy benefit.

Program InclusionSome provider‑administered specialty drugs may be included in Medical Pharmacy tier programs and may be subject to prior authorization.

Responsible Steps Program

Program PurposeResponsible Steps is a step‑therapy program for certain physician‑administered drugs that requires trial of one or more prerequisite covered medications before coverage of the Responsible Steps medication.

OverrideProviders may request a prior authorization override for medical reasons if the prerequisite cannot be used.

ApplicabilityApplies to select drugs and may include medications administered in a physician's office (medical pharmacy).

Coverage Exception

PurposeCoverage Exception process allows requests for non‑formulary medications or deviations from step‑therapy protocols via standard or expedited exception requests.

SubmissionException requests may be submitted by the prescriber, member, or designee using the Coverage Exception Request Form.

TimelinesDecision timelines: standard requests — notified within 72 hours; expedited requests — notified within 24 hours for exigent circumstances.

KEY legend — Abbreviations

PAPrior Authorization — coverage requires pre‑approval before the drug will be covered.

LDLimited Distribution — product distribution is limited to specific channels designated by the manufacturer.

SPSpecialty — product designated and managed as a specialty medication (often requiring specialty pharmacy).

STST = Responsible Steps (step therapy) — prerequisite drug(s) may be required before coverage of the listed medication.

QLQuantity Limit (QL) — maximum quantity allowed per specified time period.

PA — Prior Authorization

Prior Authorization (PA)Prior Authorization — coverage requires pre‑approval from Florida Blue before the drug will be covered.

UseIf the PA indicator is present on the medication list, providers must submit a PA request; claims may be denied without an approved PA.

DocumentationProviders must supply supporting documentation when requesting PA; specific clinical criteria are provided with the PA decision letter.

QL — Quantity Limit

Quantity Limit (QL)Quantity Limit — the maximum quantity that can be dispensed over a given period (e.g., vaccines commonly 1 vaccine/90 days; Shingrix 2 vaccines/1 lifetime).

ApplicationMedications with a QL indicator in the medication list are subject to the specified maximum quantity and time period.

OverridesProviders can request an override when a larger quantity is medically required via the Responsible Quantity/exception process.

SP — Specialty

Specialty (SP)Specialty — product managed as a specialty medication, often high‑cost and requiring special handling, storage, distribution, or monitoring.

ChannelSpecialty products are typically dispensed through a Specialty Pharmacy and may require use of preferred specialty channels for in‑network coverage.

BenefitSome specialty medications administered by a provider are covered under the medical benefit rather than the pharmacy benefit.

LD — Limited Distribution

Limited Distribution (LD)Limited Distribution — certain drugs are distributed through one or a limited number of specialty pharmacies chosen by the manufacturer.

ImplicationLD drugs may require channel‑specific sourcing and adherence to manufacturer distribution networks for coverage.

Prior AuthorizationLD products commonly also have PA and QL requirements; claims may be denied if distribution constraints are not met.

PA — Prior Authorization (coverage requires pre-approval)

PA — DefinitionPrior Authorization: when a PA indicator is present, the prescriber must submit a prior authorization request; coverage is contingent on approval.

ConsequencesIf PA is not requested/received or criteria are not met, the medication will not be covered and the member may be financially responsible.

Duration NoteApproved PAs expire on the earlier of the policy termination date or the period authorized by Florida Blue (not to exceed 12 months).

SP — Specialty (medication designation)

SP — Specialty (legend)Specialty: product managed as a specialty medication and typically handled through specialty pharmacy channels.

ExamplesMany high‑cost agents (immune globulins, antineoplastics, oral oncology agents) are designated SP in the medication list.

Coverage PathwaySpecialty designation may trigger PA, LD, and QL utilization controls.

LD — Limited Distribution (distribution channels)

LD — Limited DistributionLimited Distribution: product distribution is limited to specific channels or specialty pharmacies designated by the manufacturer.

Coverage RequirementLD products may require sourcing from specified pharmacies and often have PA and QL requirements listed.

Denial RiskClaims may be denied if LD distribution constraints are not met.

QL — Quantity Limit examples

QL — ExamplesQuantity limits include examples such as 1 vaccine/90 days for many pneumococcal vaccines and 2 vaccines/1 lifetime for Shingrix.

Vaccine QLsPNEUMOVAX 23, PREVNAR 20, and VAXNEUVANCE: QL = 1 vaccine/90 days; SHINGRIX: QL = 2 vaccines/1 lifetime.

ApplicationQLs are specified in the medication list next to each product and govern dispensing frequency.

PA / LD / QL — Legend reiteration

Legend — PA / LD / QLPA = Prior Authorization; LD = Limited Distribution; QL = Quantity Limit (Max Quantity/Time).

UsageThese codes appear in the Requirements/Limits column of the medication list to indicate utilization controls that may apply to coverage.

InterplayProducts may carry multiple flags (e.g., PA + LD + QL) requiring compliance with all noted controls for coverage.

ST — Responsible Steps (legend entry)

ST — Responsible StepsST indicates Responsible Steps (step therapy); no detailed step sequence is provided in this excerpt but it signals prerequisite drug requirements may apply.

Provider ActionProviders may request PA overrides for medical reasons when prerequisites cannot be used.

ApplicabilityST appears in the legend and may apply to select products elsewhere in the formulary.

Key abbreviations summary

PAPrior Authorization — pre‑approval is required for coverage when indicated.

LDLimited Distribution — restricted dispensing channels may apply.

SPSpecialty — product designated as specialty medication requiring specialty management.

QLQuantity Limit — maximum quantity allowed per specified time period.

STResponsible Steps — step therapy indicator requiring trial of prerequisite medications when applicable.

Responsible Steps / Step-Therapy Details

Program	Description
Condition Care Rx Program	The Condition Care Rx Program encourages use of specified lower‑cost medications for certain chronic conditions and offers reduced‑cost options; members should check their Schedule of Benefits to determine applicability and cost share.
Where to confirm applicability	Check the member's Schedule of Benefits or the member section of www.floridablue.com for program details and applicable cost share.

Requirement	Details
Prerequisite medication trial	Responsible Steps requires members to try one or more covered alternative (prerequisite) medications before the Responsible Steps medication is covered.
Provider exemption process	If a patient cannot use the prerequisite drug for medical reasons, the provider may request an override via prior authorization; if approved, coverage for the Responsible Steps medication will be provided.

Who is affected	Action required
Members prescribed Responsible Steps medications	Members must have tried the specified prerequisite drug(s) prior to approval unless a prior authorization override is granted for medical reasons.
Providers	Providers may submit a prior authorization request to request an exemption/override when a prerequisite medication is medically inappropriate.

Drug	Designation / Requirements
NUZYRA (omadacycline) 150 mg tablets	Designated Specialty (SP); Requirements/Limits: Prior Authorization (PA), Limited Distribution (LD), Quantity Limit QL (30 tablets/180 days).

Drug group	Designation / Requirements
Selected hepatitis C regimens (examples: EPCLUSA, MAVYRET, VOSEVI)	Designated Specialty (SP) where noted; Prior Authorization (PA) is required and quantity limits (QL) apply per listing.

Issue	Notes
Limited‑distribution products (LD)	Some products are identified as Limited Distribution (LD) requiring sourcing through specified channels; no explicit step sequence is provided in the excerpt.

Step Therapy details	Summary
Explicit step sequences	No explicit step therapy steps are listed in this segment; the key defines 'ST' as 'Responsible Steps' but detailed sequences are not provided in the excerpt.

Presence of ST flag	Implication
ST indicated on some specialty/high‑tier agents	The 'ST = Responsible Steps' indicator appears for select agents, signaling that step therapy may apply where listed.

Therapeutic examples	Responsible Steps note
Antidiabetic combination products (examples)	Multiple antidiabetic agents and combinations (e.g., FARXIGA, GLYXAMBI, JANUMET / JANUMET XR, JANUVIA, JARDIANCE, SYNJARDY, TRIJARDY XR, XIGDUO XR) are marked with ST indicating Responsible Steps may apply.

Legend indicator	Meaning
ST in document legend	The legend includes 'ST = Responsible Steps', indicating that step therapy requirements may apply to products noted elsewhere in the formulary.

Applicability	Provider responsibility
Where Responsible Steps applies	When a product is noted with 'ST', prescribers must follow the Responsible Steps program requirements when applicable; providers can seek PA overrides for medical reasons.

Quantity Limits and Examples

Specialty medications (general)

Standard SupplySpecialty medications are generally dispensed as a one‑month supply (standard).

ExceptionsSome specialty products may vary from the one‑month supply due to manufacturer package size or FDA‑approved dosing for a course of therapy.

Check PlanCoverage details and any plan‑specific variations are provided in the member's plan documents and Schedule of Benefits.

Responsible Quantity Drugs

Responsible Quantity DrugsMaximum quantity per month is specified for Responsible Quantity Drugs as indicated in the medication list.

BasisQuantity limits are based on FDA guidance and manufacturer dosing recommendations.

Override ProcessProviders can request an override when a larger quantity is medically required via the Responsible Quantity authorization process.

fidaxomicin susp 40 mg/ml (DIFICID)

DIFICID (fidaxomicin) suspension 40 mg/mlQuantity Limit: 272 mls (QL 272 mls/180 days).

Tier/FlagsListed with Drug Tier = 5 and QL specified in the medication list.

OverrideOverrides available if larger quantity is medically necessary as per Responsible Quantity Program.

fidaxomicin tab 200 mg (DIFICID)

DIFICID (fidaxomicin) tablets 200 mgQuantity Limit: 40 tablets (QL 40 tablets/180 days).

Tier/FlagsListed with Drug Tier = 5 and QL specified in the medication list.

Coverage NoteCoverage subject to meeting listed QL and any PA if applicable.

itraconazole (Sporanox) — capsules & oral solution

Itraconazole capsules 100 mg (Sporanox)Quantity Limit: 120 capsules (QL 120 capsules/30 days).

Itraconazole oral solution 10 mg/ml (Sporanox)Quantity Limit: 1200 mls (QL 1200 mls/30 days).

Tier/FlagsEntries listed with Drug Tier = 5 and QL (and PA where indicated) in the medication list.

terbinafine hcl tab 250 mg

Terbinafine HCl 250 mg tabletsQuantity Limit: 30 tablets per 30 days.

TierListed in medication list with specified QL.

Coverage NoteCoverage subject to listed Requirements/Limits; overrides possible if medically necessary.

Selected antiviral/HIV product quantity limits

Ziagen — abacavir sulfate solution 20 mg/mlQuantity Limit: 960 mls per 30 days.

BARACLUDE — entecavir oral solution 0.05 mg/mlQuantity Limit: 630 mls per 30 days.

HIV combination productsVarious HIV combination products listed with QL commonly 30 tablets per 30 days.

SIRTURO / PRETOMANID examples

SIRTURO (bedaquiline) tabletsQuantity Limits: examples include 940 tablets/365 days and 188 tablets/365 days (strength‑dependent).

PRETOMANID (pretomanid) 200 mg tabletsQuantity Limit: 182 tablets/365 days.

LD/PA FlagsThese antimycobacterial agents commonly carry PA, LD, and QL flags in the medication list.

darunavir 600 mg

Darunavir 600 mgQuantity Limit: 60 tablets per 30 days (QL 60/30d).

Darunavir 800 mgQuantity Limit: 30 tablets per 30 days (QL 30/30d).

Tier/FlagsListed with Drug Tier = 5 and QL in the medication list.

darunavir 800 mg

Darunavir 800 mgQuantity Limit: 30 tablets per 30 days (QL 30/30d).

Tier/FlagsListed with Drug Tier = 5 and QL in the medication list.

Coverage NoteCoverage subject to meeting the specified QL and any PA if indicated.

EPCLUSA / MAVYRET

EPCLUSA (sofosbuvir-velpatasvir)PA and QL apply: 28 tablets per 28 days.

MAVYRET (glecaprevir-pibrentasvir)PA and QL apply: 84 tablets per 28 days or pellet pack QL 140 packets per 28 days.

Coverage NoteBoth products are specialty antiviral agents with PA and QL controls listed in the medication guide.

SUNLENCA, PAXLOVID, and selected antiviral QLs

SUNLENCA (lenacapavir)Limited Distribution and QL: 4 tablets per 365 days (or therapy pack limits).

PAXLOVID packagingPAXLOVID packaging variations have QL ranging from 11 to 30 tablets per 30 days depending on pack size.

TRIUMEQ / TRUVADA / VEMLIDYExamples of QLs for antiviral agents (e.g., TRIUMEQ 180 tablets/30 days; TRUVADA 30 tablets/30 days; VEMLIDY 30 tablets/30 days).

Selected quantity limit highlights (REPATHA, VYNDAMAX, etc.)

REPATHA (prefilled syringe)Quantity Limit: 6 syringes per 28 days.

REPATHA SURECLICK (auto-injector)Quantity Limit: 6 pens per 28 days.

VYNDAMAXQuantity Limit: 30 capsules per 30 days.

ValueScript Rx Medication Guide (Formulary) — Coverage Criteria

Sign up for all Florida Blue policy alerts

Coverage Criteria and General Policy Rules

Coding, Identifiers, and Administrative Flags

Provider Requirements, Prior Authorization, and Documentation

Background and Scope

Definitions and Key Legend

Responsible Steps / Step-Therapy Details

Quantity Limits and Examples

Site of Care and Dispensing Channels