Protocol Exemption Request for Providers
To prescribe a medication, medical procedure or treatment for a condition that is different from the step-therapy protocol developed by Florida Blue, you can request an exemption for a patient by submitting a Protocol Exemption Request.
How to submit a Protocol Exemption Request for medical procedures, treatments, or medications under a medical benefit:
- Providers:
- Use the Provider Protocol Exemption Request form (PDF) for medical procedures, course of treatment, and medications reviewed by Florida Blue.
- Use the Magellan Rx Management (MRxM) Step Therapy Exemption form (PDF) for any medications included in the Provider Administered Drug Program (PADP) (PDF) and reviewed by MRxM.
- Members:
- Use the Provider Protocol Exemption Request form (PDF)
The following instructions apply to both members and health care providers.
- Complete the entire applicable form above along with the request for authorization services and/or medications prescribed to treat the medical condition. Fax the request and all necessary documents. Please be sure to provide all necessary medical records and documentation required for Florida Blue or delegated Care Partner to determine an exemption.
How to submit a Protocol Exemption Request for self-administered medications under a pharmacy benefit:
- Use 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 (external website). Be sure to provide all necessary medical records and documentation required for us to determine an exemption.
- Step Therapy forms (external website)
- Prior Authorizations forms (external website)
Important information for all Protocol Exemption Requests:
- Please do not use the Protocol Exemption Request if your Pre-Service Request was denied. If a Pre-Service Request was denied, 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 will notify you and the member with the result by letter.
If the protocol exemption request is denied, you or the member can appeal by submitting a completed appeal form based on your benefit. Please allow 30 days for appeals to be reviewed.