Florida Blue Coverage Criteria
Latest Florida Blue coverage criteria updates9
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01BlueMedicare Complete Rx formulary (Comprehensive Formulary) — Prescription drug coverage criteriaThis document governs the prescription drugs covered under the BlueMedicare Complete Rx (PDP) plan and describes coverage rules, restrictions, member rights, and how to use the formulary for plan enrollees and their prescribers.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Medicare Part B Step Therapy — Pharmacy & Specialty Drugs coverage criteriaUpdates to Florida Blue Medicare Part B Step Therapy categories, adding three new categories and revising preferred and non-preferred product lists; applies to Florida Blue Medicare plans and providers prescribing Part B drugs.All Florida Blue updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2024-10-17Sepsis PolicyGoverns Florida Blue's inpatient claim payment and coding review for diagnoses of sepsis, applying Sepsis-3 clinical criteria to validate inpatient sepsis coding and reimbursement for all lines of business and providers.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Prior Authorization Program for Prescription Medications (Coverage Criteria)Defines Florida Blue's prior authorization (PA) program processes for prescription and provider‑administered medications, including submission channels and variability by member plan; applies to providers and pharmacies interacting with Florida Blue members.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Annual Wellness Visit (AWV) and Related Preventive Visit Coverage CriteriaDefines coverage, frequency, components, eligible providers, and billing guidance for the Medicare Annual Wellness Visit and related preventive examinations for Florida Blue members.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyBehavioral health levels of care (Inpatient, Residential, PHP) — Coverage criteriaDefines levels of behavioral health care (Inpatient, Residential, Partial Hospitalization) and the clinical focus, description, and typical duration/intensity for each; intended for providers managing member placement and referrals.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyPart B Drug Prior Authorization Request Form Coverage CriteriaForm and instructions for providers to request prior authorization for Medicare Part B drugs from Florida Blue; applies to prescribers submitting requests for coverage or continuation of Part B drugs.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyStep Therapy Exemption Request Form Coverage CriteriaForm and instructions for providers and members to request an exemption from a health plan's pharmacy step therapy protocol; affects prescribers, members, and Prime Therapeutics staff processing Florida Blue plan requests.All Florida Blue updates
- Coverage CriteriaClinical/Medical PolicyValueScript Rx Medication Guide (Formulary) — Coverage CriteriaDefines 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.All Florida Blue updates
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Tool Description
Search Florida Blue coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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