CurrentAnthemPolicy N/A

Uniform Pharmacy Prior Authorization Request Form

This document is a standardized prior authorization request form for pharmacy drug benefits, governing how providers submit prior authorization requests and the information required; it affects prescribing providers, pharmacies, and prior authorization staff for Anthem members.

Policy Summary

PayerAnthem

PolicyUniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the uniform pharmacy prior authorization request form to the Prior Authorization Benefits Center and indicate urgency, request type, and required patient, prescriber, diagnosis, and drug information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number for submission

2form pages/chunks provided

12 monthsreauth exception timeframe

2urgency categories

Clinical Criteria and Form-based Decision Points

Form-based criteria capture

Form includes a section to capture clinical criteria, prior therapies, and the approval decision. Complete all applicable fields to support the prior authorization determination.

Complete the Clinical Criteria for Approval section with pertinent information to support the request, including other medications tried, their name(s), duration, and patient response.

Indicate whether the medication is for use in a clinical trial; if yes, provide trial name and registration number.

Record drug details: Drug name (brand and scientific), strength, dose, route, frequency, quantity, and number of refills.

Provide location of treatment (e.g., provider office, facility, home health), including provider name, Type 2 NPI (if applicable), address, and tax ID; include dispensing pharmacy name and phone number.

Policy Summary

PayerAnthem

PolicyUniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Diagnostic and Drug Coding / Timeframe Exceptions

Diagnostic and drug coding fieldsmixed

No codes listed

Authorization timeframe exception

Authorization timeframe exceptionIf the date of the first prior authorization request is greater than twelve (12) months ago, the prior authorization request form is not required.

How it applies on the formThe form asks for the date of the first request and instructs that if >12 months since that date, do not complete the form.

Where to find on form‘If No, what was the date of the first request? *If greater than twelve (12) months since the first request, prior authorization request form is not required.’ (Date field provided)

Submission Requirements and Handling

Prior Authorization

Submit completed prior authorization form (fax to Prior Authorization Benefits Center) and note special-case exceptions

Complete the Uniform Pharmacy Prior Authorization Request Form in its entirety and fax it to the Prior Authorization Benefits Center at 844-521-6939. On the form indicate urgency (Urgent or Non‑Urgent), whether the request is a New Request or a Reauthorization, and provide all required patient, prescriber, diagnosis (including ICD codes), and drug information requested on the form. For requests for medications intended to treat opioid dependence, if this is the first prior authorization request for that drug, prior authorization is not required and the form need not be completed; if a reauthorization is requested and the first request was more than twelve (12) months earlier, the prior authorization request form is not required.

Fax completed form to Prior Authorization Benefits Center: 844-521-6939. [[DO NOT PLACE CHUNK REFS IN BODY]]
Check urgency: Urgent or Non‑Urgent (form has checkboxes).
Indicate New Request or Reauthorization (form has checkboxes).
Provide patient name, member/subscriber number, DOB, address, phone, and diagnosis/ICD code(s).
Provide prescriber name, NPI, DEA, phone, fax, address, specialty/facility, and authorized signature.
List drug(s) requested (with J‑code if applicable), strength/route/frequency, unit/volume, start date and length of therapy, and delivery location.
Opioid dependence: if first request for the drug, prior authorization is not required — do not complete the form.
If reauthorization and the date of the first request is greater than twelve (12) months prior, prior authorization form is not required.

Exceptions and Defined Terms

Opioid dependence first-request exception

Opioid dependence first-request exceptionIf the drug is intended to treat opioid dependence and this is the first prior authorization request for that drug, prior authorization is not required and the form does not need to be completed.

How the form captures itForm asks: ‘Is this drug intended to treat opioid dependence?’ and if yes: ‘Is this the first request for prior authorization for this drug?’ with instruction that if yes, prior authorization is not required.

Provider actionDo not submit the prior authorization form for first-time requests of medications intended to treat opioid dependence.

Twelve-month reauthorization exception

Twelve-month reauthorization exceptionIf it has been greater than twelve (12) months since the date of the first prior authorization request, the prior authorization request form is not required.

Form field requirementThe form includes a date field for the first request and the explicit instruction that if >12 months have passed, the form need not be completed.

Interaction with reauthorization optionWhen ‘Reauthorization’ is selected, providers must check the first-request date; if >12 months, they should not submit the form.