New-to-market and Self-Administered Specialty Drug Coverage List
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This document lists newly marketed and self-administered specialty medications and indicates coverage controls (Limited Distribution Drug, Prior Authorization, Quantity Limits) and plan-specific notes relevant to Florida Blue members and providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Annotations
Illustrative coverage flag criteria
Coverage stance is indicated per drug using flags; newly marketed drugs require Pharmacy & Therapeutics (P&T) Committee review before a coverage determination is made.
ALL of the following
Examples
- Abilify Maintena — LDD
- abiraterone (abirtega) — PA, QL
- Acthar Gel — LDD, PA, QL
- Selected hemophilia products — PA; preferred pharmacy: CVS/Caremark
- Some listed items — NOT COVERED (applies to specific NDCs/brands as listed)
Coverage annotations and operational rules
Drugs are annotated individually; common policy stances and operational rules are described below.
Coverage Codes and Coding Notes
| LDD | Limited Distribution Drug (dispensing pharmacy specific) |
| PA | Prior Authorization required |
| QL | Quantity Limit |
| LDD | Limited Distribution Drug (dispensing pharmacy identified separately) |
| PA | Prior Authorization required |
| QL | Quantity Limit applies |
| NOT COVERED | Drug not covered |
Provider Actions, Prior Authorization, and Dispensing
Prior Authorization and Distribution controls
Prior Authorization (PA) and Quantity Limit (QL) requirements apply to many specialty drugs; certain specialty drugs may be Limited Distribution Drugs (LDD) and available only from specific pharmacies. Members and providers should refer to the member contract and Prior Authorization Program Information and Forms and contact Customer Service for questions.
- PA and QL are applied to many listed specialty drugs (see drug table entries).
- LDD denotes drugs available only from specific dispensing pharmacies; the appropriate dispensing pharmacy can be found at the Limited Distribution Drugs link.
- Contact Customer Service or consult the member contract and PA program forms for plan-specific applicability.
Preferred specialty pharmacy — hemophilia products
CVS/Caremark is the preferred in-network pharmacy for hemophilia products; hemophilia-related products are flagged with a special notation (2) in the drug list.
- Hemophilia products in the list include the notation '2' to indicate CVS/Caremark preference.
- Member cost share may be higher for self‑administered specialty drugs not obtained at in‑network specialty pharmacies.
Prior Authorization and Distribution Constraints
Many listed specialty drugs are subject to Prior Authorization (PA) and Quantity Limits (QL); Limited Distribution Drugs (LDD) indicate dispensing constraints and specific pharmacy routing.
- Drug entries annotated with 'PA' require prior authorization before coverage is approved.
- Drug entries annotated with 'QL' are subject to quantity limits.
- Drug entries annotated with 'LDD' are limited distribution drugs with specific dispensing pharmacies.
Key Definitions and Glossary
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.