New to Market and Specialty Prescription Drug Coverage List and Prior Authorization Requirements
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Governs coverage, prior authorization, limited distribution, and quantity limits for newly marketed and specialty prescription medications for Florida Blue members and providers. Affects pharmacy benefit management, prescribing providers, and in-network specialty pharmacies.
No material clinical or coverage changes in this revision.
Coverage criteria and access rules
Coverage criteria and operational rules
Coverage and access are determined after Pharmacy Therapeutics Committee review and per member contract; many drugs require prior authorization and/or are limited distribution.
Operational guidance and access rules
- Member cost share may be higher for self-administered specialty drugs not obtained at in‑network specialty pharmacies such as Accredo or CVSICaremark Specialty Pharmacy.
- Certain specialty drugs may only be available from a specific specialty pharmacy or location (LDD) and must be obtained from that dispensing pharmacy.
- CVSICaremark is the preferred in‑network specialty pharmacy for hemophilia products.
Drug designations and coding details
| LDD | Limited Distribution Drug (dispensing pharmacy can be found on Limited Distribution Drugs list) |
| PA | Prior Authorization required |
| QL | Quantity Limit |
Prior authorization, reviews, and provider contacts
Prior Authorization and New-to-Market Review
Newly marketed prescription medications may not be covered until the Pharmacy Therapeutics Committee reviews the medication to determine coverage and tiering; many drugs on the New to Market list require Prior Authorization (PA). Refer to the member contract benefit and the Prior Authorization Program Information and Forms for PA inclusion and coverage determinations.
- Coverage and tier are determined based on safety, efficacy, and availability of other products in the class.
- Drugs marked “PA” on the New to Market list require prior authorization per the PA program.
Provider Contacts for PA and Coverage Questions
For questions about prior authorization, coverage, or the New to Market list, contact the Provider Contact Center or Member Customer Service as directed on the member ID card.
- Provider Contact Center: 1-800-727-2227 (health care providers and office staff only).
- Customer Service: phone number found on the back of the member's insurance card.
Terminology used in this policy
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