By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Resources to Get Eylea and Lucentis Covered by Blue Cross Blue Shield in Florida: Complete Forms, Portals & Appeals Guide

Answer Box: Getting Started

To get Eylea (aflibercept) or Lucentis (ranibizumab) covered by Blue Cross Blue Shield in Florida: Submit prior authorization through your ophthalmologist using Florida Blue's Availity portal or CoverMyMeds. Include OCT scans, visual acuity records, and documentation of failed bevacizumab if required by step therapy. Most approvals take 72 hours. If denied, file internal appeal within 180 days, then external review through Florida Department of Financial Services if needed. Start by calling the member services number on your ID card to verify PA requirements.

Table of Contents

  1. Verify Your Plan & Find the Right Policy
  2. Required Forms & Documentation
  3. Submission Portals & Electronic Options
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Phone Lines & Case Management
  7. Florida Appeal Process & Regulatory Help
  8. Update Schedule & Staying Current

I. Verify Your Plan & Find the Right Policy

Before submitting any paperwork, confirm your specific Florida Blue plan type and current policy requirements.

Check Your Coverage First

  1. Look at your ID card - Note whether it says "Florida Blue," "BlueMedicare," or "FEP Blue"
  2. Call member services at the number on your card's back to verify:
    • Whether Eylea/Lucentis requires prior authorization
    • Your formulary tier (typically Tier 4-5 specialty)
    • Any step therapy requirements (often bevacizumab first)
    • Quantity limits per injection cycle

Find Your Current Policy

Florida Blue's anti-VEGF coverage falls under Medical Policy 09-J1000-78: "Vascular Endothelial Growth Factor Inhibitors for Ocular Indications" (verify current policy). This policy covers wet AMD, diabetic macular edema, and retinal vein occlusion indications.

Note: As of 2024, Florida Blue Medicare Advantage added Part B step therapy requirements for anti-VEGF drugs, often requiring bevacizumab trials first.

II. Required Forms & Documentation

Core Prior Authorization Requirements

Florida Blue doesn't use a single "Eylea/Lucentis form" but requires comprehensive clinical documentation through their standard PA channels:

Essential Documents:

  • Member demographics and plan information
  • Specific drug request (Eylea 2mg vs. Lucentis 0.5mg, injection frequency)
  • ICD-10 diagnosis codes (H35.32xx for wet AMD, E11.351x for diabetic retinopathy)
  • OCT scan results showing macular edema or fluid
  • Best-corrected visual acuity measurements
  • Prior treatment history, especially bevacizumab use/failure

Medical Necessity Documentation

Your ophthalmologist must provide:

  1. Diagnostic Evidence
    • OCT showing central retinal thickness >300 microns or intraretinal/subretinal fluid
    • Fluorescein angiography documenting choroidal neovascularization (if available)
    • Color fundus photos showing hemorrhage or exudates
  2. Treatment History
    • Dates and outcomes of previous anti-VEGF injections
    • Visual acuity response over time
    • Reasons for switching agents (inadequate response, intolerance, contraindications)
  3. Step Therapy Documentation (Medicare Advantage plans)
    • Number of bevacizumab injections attempted
    • Objective evidence of treatment failure (persistent edema on OCT, vision loss)
    • Medical contraindications to preferred agents

III. Submission Portals & Electronic Options

Primary Electronic Channels

For Medical Benefit (Office-Administered) Injections:

  • Availity Provider Portal - Florida Blue's preferred method for Part B drug PAs
  • Login required for providers; includes document upload capability
  • Status tracking available in real-time

For Pharmacy Benefit Specialty Drugs:

  • CoverMyMeds - Electronic PA platform integrated with Florida Blue/Prime Therapeutics
  • Fastest processing for specialty pharmacy fills
  • Automatic status updates to prescriber

Required Provider Accounts

Your eye care provider needs active accounts on:

  • Availity (for medical benefit PAs)
  • CoverMyMeds (for pharmacy benefit requests)
  • Florida Blue Provider Portal (for policy updates and forms)

Patient Role: You cannot submit PAs directly - your ophthalmologist or retina specialist must handle all submissions.

IV. Fax Numbers & Mailing Addresses

Important: Form-Specific Fax Numbers

Florida Blue prints the correct fax number on each PA form rather than maintaining universal numbers. Always use the fax number printed on your specific form.

General Guidance:

  • Medical PA requests: Fax number varies by form type (commercial vs. Medicare)
  • CVS Specialty fills: Use CVS Specialty Fax Form with printed fax number
  • Part B drug PAs: Download current "Part B Drug Prior Authorization Request Form" for correct fax

Cover Sheet Best Practices

When faxing PA requests:

  • Include member ID, provider NPI, and urgency level
  • Attach all supporting clinical documentation
  • Request delivery confirmation
  • Follow up within 2 business days if no acknowledgment
Tip: Electronic submission through Availity or CoverMyMeds typically processes faster than fax and provides automatic confirmation.

V. Specialty Pharmacy Setup

Florida Blue Contracted Specialty Pharmacies

Accredo Specialty Pharmacy

  • Phone: 888-425-5970
  • Fax: 888-302-1028
  • Handles most specialty injectables including Eylea/Lucentis

CVS/Caremark Specialty Pharmacy

  • All products: 866-278-5108
  • Fax: 800-323-2445
  • Integrated with CoverMyMeds for PA processing

Transfer Process

  1. Provider initiates transfer from current pharmacy
  2. Specialty pharmacy contacts patient for insurance verification
  3. PA approval confirmed before first shipment
  4. Delivery coordination with injection appointments

Patient responsibilities: Provide insurance cards, confirm delivery address, and coordinate with your eye doctor's injection schedule.

VI. Support Phone Lines & Case Management

Member Services Contacts

Primary Contact: Use the member services number on your ID card for plan-specific questions about specialty drug coverage and copays.

Florida Blue Prior Authorization Line: 1-877-719-2583

  • Medical services and Part B drug PAs
  • Provider and member inquiries
  • Status checks and expedited requests

Prime Therapeutics (Florida Blue's PBM): 800-424-4947

  • Physician-administered drug program
  • Specialty pharmacy coordination
  • Step therapy exceptions

Specialty Drug Case Management

Florida Blue offers dedicated case management for members with high-cost specialty conditions:

Case Management Services Include:

  • Coordination with specialty pharmacies
  • Copay assistance program navigation
  • Treatment adherence support
  • Provider communication facilitation

To Access: Call member services and request connection to "Case Management" or "Care Management" for specialty drug support.

What to Ask When You Call

For Coverage Questions:

  • "Is [Eylea/Lucentis] covered under my medical or pharmacy benefit?"
  • "What's my copay/coinsurance for specialty injectables?"
  • "Do I need step therapy with bevacizumab first?"
  • "Which specialty pharmacy is in-network for my plan?"

For PA Status:

  • "What's the status of PA request for [member ID]?"
  • "What additional documentation is needed?"
  • "Can this be expedited for urgent vision loss?"

VII. Florida Appeal Process & Regulatory Help

Internal Appeal Process

Timeline: 180 days from denial notice to file internal appeal

Required Documentation:

  • Original denial letter with claim/PA numbers
  • Point-by-point rebuttal addressing denial reasons
  • Updated clinical records and imaging
  • Prescriber letter supporting medical necessity
  • Peer-reviewed literature on drug efficacy

Submission: Use Florida Blue's Provider Clinical Appeal Form (available on provider forms page) or submit via Availity portal.

External Review Option

If internal appeal fails, Florida residents can request external review through the Florida Department of Financial Services (DFS).

Contact Information:

  • Phone: 877-693-5236 (Consumer Helpline)
  • Email: [email protected]
  • Online: DFS eService portal

Timeline: 4 months from final internal denial to request external review

Process: Independent medical experts review your case; their decision is binding on Florida Blue.

2025 Enhanced Appeal Rights

New Florida regulations require insurers to:

  • Process appeals 7 days per week
  • Complete concurrent reviews within 24 hours for ongoing treatments
  • Face automatic regulatory review for delays via 1-800-FL-HEALTH hotline

Counterforce Health can help streamline your appeal process by analyzing denial letters, identifying the specific policy criteria at issue, and drafting targeted rebuttals with the right clinical evidence and regulatory citations. Learn more about our appeal assistance.

VIII. Update Schedule & Staying Current

How Often to Check Resources

Quarterly (Every 3 Months):

  • Formulary changes and tier updates
  • PA form revisions and new submission requirements
  • Specialty pharmacy network changes

Annually (January):

  • Major policy updates, especially for Medicare Advantage
  • New step therapy requirements
  • Coverage criteria modifications

Where to Find Updates

Florida Blue Provider Portal:

  • Medical policy updates and bulletins
  • New PA forms and submission guidelines
  • Specialty pharmacy network changes

Key Resources to Bookmark:

From our advocates: We've seen cases where patients successfully overturned denials by submitting updated OCT scans showing disease progression despite previous treatments. The key was demonstrating objective worsening that standard step therapy couldn't address. Always include the most recent imaging and visual acuity measurements in your appeal.

Coverage at a Glance

Requirement What it means Where to find it
Prior Authorization Required for both Eylea and Lucentis Florida Blue PA page
Step Therapy Often requires bevacizumab trial first (Medicare Advantage) Medical Policy 09-J1000-78
Diagnosis Documentation OCT scans and visual acuity required Provider clinical notes
Formulary Tier Typically Tier 4-5 specialty Member ID card or call member services
Appeal Deadline 180 days from denial notice Florida Blue denial letter
External Review Available through Florida DFS DFS Consumer Services

Frequently Asked Questions

How long does Florida Blue PA approval take? Standard review is 72 hours; expedited review for urgent vision loss is 24 hours. Submit complete documentation to avoid delays.

What if Eylea/Lucentis is non-formulary on my plan? Request a formulary exception through your provider using medical necessity documentation. Include evidence that formulary alternatives are inappropriate.

Can I get an expedited appeal for vision-threatening conditions? Yes, both internal appeals and external reviews can be expedited for urgent medical situations. Request this when filing.

Does step therapy apply if I failed bevacizumab in another state? Yes, document the prior treatment history with dates, outcomes, and reasons for discontinuation. This should satisfy step therapy requirements.

What's my copay for specialty anti-VEGF injections? Copays vary by plan but typically range from $50-$500 per injection for specialty tiers. Call member services for your specific amount.

How do I find an in-network retina specialist? Use Florida Blue's provider directory online or call member services. Ensure the provider is credentialed for specialty drug administration.

When dealing with specialty medication denials, having expert support can make the difference between approval and continued delays. Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific policy gaps and crafting evidence-based rebuttals that align with each payer's requirements. Visit our website to learn how we can help with your case.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider about treatment options and work with your insurance plan directly for coverage determinations. For assistance with insurance appeals and denials in Florida, contact the Department of Financial Services Consumer Helpline at 877-693-5236.

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