Florida Blue Prior Authorization Lookup
Latest Florida Blue prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Responsible Steps Program (step therapy and prior authorization guidance)Describes Florida Blue's Responsible Steps Program which lists therapeutic categories, target drugs, and prerequisite (step) therapy requirements that govern prior authorization and coverage for covered members. Affects providers submitting pharmacy authorizations for Florida Blue members enrolled in the program.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Prior Authorization Program Information and Authorization FormsLists numerous drug products with routing (CoverMyMeds vs Availity) and preferred-agent notes (biosimilars, insulin products that do not require PA).All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Responsible Steps Program Information and Authorization FormsProvides lists of target drugs by therapeutic category and the prerequisite prior-use (step) medications required for prior authorization within the Responsible Steps Program; links to authorization forms are referenced. Covers many classes (antidepressants, atypical antipsychotics, gabapentin-related products, SGLT2 inhibitors, phosphate binders, topical corticosteroids, atopic dermatitis agents, etc.) and specifies required prior use (generic agents, number required, or condition-specific alternatives).All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Medical/Specialty Pharmacy (Rx) Drug Prior Authorization RequirementsDefines Florida Blue requirements and submission routing for prior authorization of Medical/Specialty Pharmacy drugs billed through the medical benefit and lists drugs/HCPCS that require prior authorization for applicable products and settings.All Florida Blue updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Newly Marketed and Specialty Prescription Drug Coverage and Utilization ControlsGovernance of coverage, prior authorization, quantity limits, limited distribution designation, and preferred specialty pharmacy arrangements for newly marketed and specialty prescription medications for Florida Blue members; affects prescribers, pharmacies, and members covered by Florida Blue plans.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Provider Administered Drug Program (PADP) — Prior Authorization and PADP Drug ListDefines the Provider Administered Drug Program (PADP) managed by Prime Therapeutics (Magellan Rx Management) for Florida Blue and Health Options, specifying which provider settings, member products, and HCPCS/J-codes require prior authorization and are managed under the program.All Florida Blue updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Provider Administered Specialty DrugsThis document lists provider-administered specialty drugs subject to medical benefit coverage, notes prior authorization (PA), limited distribution drug (LDD) status, and other program details for providers and members of Florida Blue.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Responsible Steps Program prior authorization and prerequisite (step) therapy criteria for specialty and behavioral health drugsDefines drugs included in Florida Blue's Responsible Steps Program and prerequisite (step) drug use requirements that must be met for authorization; applies to providers prescribing the listed specialty/behavioral health drugs for members covered by Florida Blue.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Medicare Part B Step Therapy — Colony-Stimulating FactorsThis policy governs updated Step Therapy requirements for certain nonpreferred Part B medications (colony-stimulating factors) for Florida Blue Medicare Advantage (BlueMedicare) plans and informs prescribers of preferred alternatives and prior authorization expectations.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Newly Marketed and Self‑Administered Specialty Drugs — Coverage List and Prior Authorization RequirementsLists newly marketed prescription and specialty medications with prior authorization (PA), quantity limits (QL), and limited distribution drug (LDD) designations; informs providers and pharmacies about coverage requirements and dispensing channels for Florida Blue members.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Site of Care Review ProcessDefines Florida Blue, Florida Blue HMO, and Truli plans' Site of Care Review Process requiring prior authorization and comparative-effectiveness review for a list of Designated Outpatient Procedures when performed in a hospital outpatient department, effective October 1, 2025; excludes certain products and ASCs.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01GLP-1 prior authorization for commercial plansDefines Florida Blue commercial plan coverage and prior authorization requirements for GLP-1 medications used to treat type 2 diabetes, and lists preferred and non-covered GLP-1 products. Applies to providers submitting pharmacy prior authorization requests for affected members.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Medical/Specialty Pharmacy Drugs Requiring Prior AuthorizationDefines Florida Blue prior authorization requirements, submission routing, and product-specific handling for medical benefit–processed specialty (Rx) drugs and identifies drugs/HCPCS/CPT codes listed for prior auth review.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Provider‑Administered Drug Program (PADP) — MRxM (Prime Therapeutics) management and prior authorizationDefines Florida Blue's PADP utilization management handled by Prime Therapeutics (MRxM) for a listed set of provider‑administered medications and the requirement that participating providers obtain prior authorization before drug administration. Applies to covered Florida Blue member products and specified places of service.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Responsible Quantity Program — Pharmacy program updates (Responsible Quantity limits, step therapy, prior authorization, coverage exclusions)Updates to Florida Blue's pharmacy programs effective April 1, 2025, including additions to the Responsible Quantity Program (drug-specific dispensing limits) and related step therapy, prior authorization, and coverage exclusion changes for members whose plans include these programs.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01RxF_Specialty_Table_Prov.pdfA 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.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2024-04-01Coverage for GLP-1 Drug Class (Commercial & Medicare) — Prior Authorization and Documentation RequirementsDefines Florida Blue commercial and Medicare pharmacy coverage and prior authorization requirements for GLP-1 class drugs, limiting coverage to FDA-approved indications for type 2 diabetes and specifying documentation and drug-specific coverage rules for affected members and providers.All Florida Blue updates
- Prior AuthReimbursement/Payment PolicyEff. 2024-04-01New-to-market and Self-Administered Specialty Drug Coverage ListThis 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.All Florida Blue updates
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2024-01-01Prior authorization policy for preferred continuous glucose monitors (CGMs) and suppliesBlueMedicare HMO and PPO Medicare Advantage patients may obtain preferred CGMs (Dexcom and FreeStyle Libre) and supplies without prior authorization; non-preferred/adjunctive CGMs still require authorization. Applies to Part B coverage channels noted in the document.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2024-01-01providers-news-2023-pharmacy-glp-1-drugs-11-2023.pdfProvider bulletin from Florida Blue describing pharmacy coverage and prior authorization requirements for the GLP-1 drug class for commercial and Medicare plans, limiting coverage to FDA‑approved indications for type 2 diabetes and excluding use for weight loss/management.All Florida Blue updates
- Prior AuthAdministrative/Operational PolicyEff. 2023-01-01Prior authorization process for continuous glucose monitors (CGMs) and suppliesGoverns prior authorization submission and dispensing process for CGMs and related supplies for Florida Blue Medicare Advantage (BlueMedicare HMO and PPO) members, affecting prescribers, pharmacies, and prior authorization workflows.All Florida Blue updates
- Prior AuthReimbursement/Payment PolicyEff. 2021-10-01New to Market and Specialty Prescription Drug Coverage List and Prior Authorization RequirementsGoverns 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.All Florida Blue updates
- Prior AuthClinical/Medical PolicyEff. 2021-10-01Provider Administered Specialty DrugsDefines coverage, prior authorization, limited distribution, and program contacts for provider-administered specialty drugs under Florida Blue medical benefits; applies to providers and facilities billing these drugs.All Florida Blue updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-01-01Oncology and Hematology Prior Authorization Program for Medicare Advantage MembersGoverns prior authorization requirements for specified oncology and hematology drugs for Florida Blue Medicare Advantage members and identifies drugs managed by New Century Health starting Jan 1, 2021.All Florida Blue updates
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Tool Description
Search Florida Blueprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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