Protocol Exemption Request for Members

Your doctor may want to prescribe a medication, medical procedure or course of treatment for a condition that is different from the step-therapy protocol developed by Florida Blue.

If this is the case, either you or your doctor can request an exemption by submitting a Protocol Exemption Request.

How to submit a Protocol Exemption Request for medical procedures, treatments, or medications under a medical benefit:

• Members: Use the Member Protocol Exemption Request form
• Providers: visit the Florida Blue Provider Site

The following instructions apply to both members and health care providers.

• Complete the entire Protocol Exemption Request form along with the request for authorization services and medications your doctor wants to use to treat your medical condition. Fax the request and all necessary documents to us at 1-877-219-9448.  Please be sure to provide all necessary medical records and documentation required for us to determine an exemption.

How to submit a Protocol Exemption Request for medications under a pharmacy benefit:¹

• You will use either the Step Therapy form or the Prior Authorization form. Submit with the step-therapy protocol to Prime Therapeutics either by fax at 1-855-212-8110 or CoverMyMeds. Please be sure to provide all necessary medical records and documentation required for us to determine an exemption. Members, if you’re not sure which form to use, call the number on the back of your member ID card.
  • Step Therapy forms
  • Prior Authorizations forms

Important information for all Protocol Exemption Requests:

• Please don’t use the Protocol Exemption Request if your Pre-Service Request was denied. If your doctor submitted a Pre-Service Request and that was denied, please follow the standard appeal process.

Florida Blue will review and determine approval or denial of your Protocol Exemption Request within 72 hours for an urgent request or 15 calendar days for a non-urgent request. We’ll notify you and your doctor with the result by letter.

If the protocol exemption request is denied, you or your doctor can appeal. To do so, submit a completed appeal form based on your benefit. Please allow 30 days for appeals to be reviewed.

• HMO Member Grievance and Appeal Form
• Non-HMO Member Grievance and Appeal Form

Have questions? We’re here to help. Call us at the number on the back of your member ID card.

Health care providers can call us at 1-800-727-2227 with questions.

¹Florida Blue’s pharmacy policies under these Utilization programs are in compliance with Florida law 627.42393.

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