Medical & Pharmacy Policies and Guidelines

Find everything you need to help your patients understand their health insurance as it relates to medical and pharmacy benefits and policies here.

• Dental Information
• Medical Policies (Medical Coverage Guidelines)
• Medication Guides
• Medical Policy and Pre-Certification Pre-Authorization Information
• Medicare Part B Step Therapy
• Pain Management
• Payment Policies
• Practice & Preventive Service Guidelines
• Prior Authorization for Medical Services

Pharmacy Utilization Management Programs

• Responsible Quantity
  Responsible Quantity is an initiative to ensure that prescription drug coverage reflects drug manufacturers' and FDA dosing guidelines.
  • Drugs included in the Responsible Quantity Program (PDF)
  • Quantity Limit Authorization Form (PDF)
    Authorization requests for use of over 4,000 mg of acetaminophen per day cannot be approved.

To request a prior authorization for a medication included in the Responsible Quantity program, download the Quantity Limit Authorization form, complete and fax to 1-877-480-8130.

You can also use CoverMyMeds to request authorization.

• Responsible Steps
  Responsible Steps is an initiative to ensure the use of a designated or prerequisite drug(s) prior to providing coverage of the drug listed as a target in the program.
  • Responsible Steps Program Information and Authorization Forms (PDF)
  • Responsible Steps for Medical Pharmacy Program Information and Authorization Forms (PDF)

To request a prior authorization for a medication included in the Step Therapy program, download the appropriate Step Therapy Prior Authorization Request form, complete and fax to 1-877-480-8130.

You can also use CoverMyMeds to request authorization.

• Prior Authorization
  Prior Authorization assures that specific clinical criteria are met in order for coverage of the drug included in the Prior Authorization program.
  • Prior Authorization Program Information and Authorization Forms (PDF)

To request a prior authorization for a medication included in this program, download the appropriate form, complete and fax to the number at the bottom of the form.

You can also use CoverMyMeds to request authorization.

Faxed forms with all required information are processed within 10 calendar days from the date received from the provider. Faxed forms with missing information may require up to 15 working days to be completed, provided missing information can be readily obtained.

• Medications Not Covered

Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are:

• The medication has been shown to have excessive adverse effects and/or safer alternatives
• The medication has a preferred formulary alternative or over-the-counter (OTC) alternative
• The medication is no longer marketed
• The medication has a widely available/distributed AB rated generic equivalent formulation
• The medication has been has been repackaged - a pharmaceutical product that is removed from the original manufacturer container (Brand Originator) and repackaged by another manufacturer with a different NDC.
• Medications Not Covered List (PDF)
• Coverage Exception Request for Individual Exchange Plan Members (PDF)
• Used to submit coverage exception request for drugs not covered and only applies to Members that have plans for individuals under 65 or small group and individuals under 65 from the Health Marketplace.

• Comparative Effectiveness Program
  Comparative Effectiveness assists healthcare decisions by using alternative treatment options for comparable ways to deliver healthcare i.e. drugs, medical devices, tests, and surgeries. This requires an authorization review requested by providers on behalf of members. A list of drugs included in the comparative effectiveness program is found below.
  • Comparative Effectiveness Program (PDF)

Pharmacy Claim Filing Instructions
Participating pharmacies should submit claims for covered prescriptions to Prime Therapeutics, LLC. It is necessary that all Florida Blue claims be transmitted using a portion of the contract number on the member's ID Card. The first three alpha characters in the contract number are not part of the member ID number and should not be used on submissions of claims. The member ID number begins with the letter H.

• Process Control Number (PCN) for BlueScript, Mediscript and BlueCare Rx members is FLBC and the member ID number is the letter H followed by 8 or 10 numeric digits.

Claims should be transmitted using Bin Number 012833. For assistance or questions related to claim filing for covered prescriptions, contact the Prime Pharmacy Help Desk at 1-888-877-6323 for non-Medicare Part D or 1-888-877-6420 for Medicare Part D.