Prior Authorization for Brand Medically Necessary (BMN) Medication
Form and process requirements for requesting prior authorization when a prescriber designates a brand drug as medically necessary instead of a substitutable generic for Anthem-served Indiana Medicaid lines of business; applies to prescribing providers and participating groups serving Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
BMN PA submission criteria
Prior authorization will be considered when the following documentation and form fields are completed and submitted:
Required submission components
- Completed BMN prior authorization form (all sections must be completed)
Form must be completed by the prescribing provider; incomplete requests will be returned.
- Prescriber signature and prescriber identification
Include prescriber name, Indiana license number and NPI on the form.
- Photocopy of completed FDA MedWatch form describing the adverse event(s) experienced with the generic equivalent
Attach a photocopy of the MedWatch form submitted to the FDA; do not submit originals. PA is contingent upon submission to FDA of the MedWatch form.
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