CurrentAnthemPolicy N/A

Pharmacy Prior Authorization Form for Anthem Indiana Programs

This document is a prior authorization (PA) request form used by providers and pharmacies to request coverage for prescription drugs (including medical injectables/oncology) for members enrolled in Anthem programs serving Indiana (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging). It describes required information and submission instructions for PA review.

Policy Summary

PayerAnthem

PolicyPharmacy Prior Authorization Form for Anthem Indiana Programs

Policy CodePolicy N/A

Change TypeAdministrative / informational form update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a fully completed PA form including required ICD-10-CM and HCPCS codes, relevant medication history and labs, and fax to 844-864-7860 for review; incomplete forms will delay processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-72 hoursexpectation for PA review / pharmacy dispensing while awaiting decision

844-864-7860fax number for PA submission

4separate phone numbers listed for plan-specific PA inquiries

Policy Snapshot

This prior authorization (PA) request form is used by providers and pharmacies to request coverage for prescription drugs, including medical injectables/oncology, for members enrolled in Anthem programs serving Indiana: Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging. It describes the information required to initiate a PA review and the submission instructions to ensure timely processing.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization Submission Requirements

The PA request will be reviewed based only on medical necessity. Requests must include the following information; incomplete requests will delay processing:

ALL of the following

Completed form in its entirety (all relevant sections filled).
Any incomplete sections will result in a delay in processing.
An ICD-10-CM diagnosis code is required for all requests.
An HCPCS billing code is required for all medical injectable/oncology requests.
Member demographic and residence information (including DOB, sex, place of residence).
Medication information: drug name and strength, SIG (dose, frequency, duration), HCPCS code (if applicable), diagnosis/indication, ICD-10-CM code.
Provider information: prescriber name, NPI (required), address where service was rendered, phone, fax, DEA/license number.
Billing facility information when different from requesting physician: facility name, NPI/tax ID (required), DEA/license number, address, contact info.
Pharmacy information: pharmacy name, pharmacy NPI, phone, fax (when pharmacy is requester).
Documentation of prior medication trials related to the condition (yes/no). If yes, provide drug name/strength, date range, SIG, and outcome (adverse reaction, inadequate response, other) with details.
Supporting documentation may be requested (medical records, office notes, FDA MedWatch).
List of current medications (dose and frequency).
Diagnostic studies and/or laboratory tests performed within the past 30 days related to the diagnosis or medication requested (test name, date, result).
Signature and date from prescriber or authorized representative certifying accuracy.

Submission and Processing Logistics

Operational expectations and contact points for PA submission and follow-up:

ALL of the following

Fax completed form and supporting documentation to 844-864-7860.
Allow at least 24 hours for review.
The pharmacy may dispense up to a 72-hour supply while awaiting the outcome; contact the member's pharmacy.
Plan-specific PA inquiry phone numbers are provided for different programs (Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, Indiana PathWays for Aging).
Requests are reviewed only for medical necessity; approval does not guarantee payment (subject to eligibility, other coverages, and program restrictions).

What Providers Must Do

Prior Authorization

Submit completed PA form and supporting documentation

Complete the PA form in its entirety, including required diagnosis and billing codes where applicable, document prior medication trials and relevant laboratory or diagnostic test results, and fax the completed form and supporting documentation to 844-864-7860 for review. Incomplete forms will delay processing.

Required codes: ICD-10-CM (all requests)
HCPCS (required for medical injectable/oncology requests)
Fax: 844-864-7860

Documentation Required

Supply supporting clinical records on request

Be prepared to provide copies of medical records, office notes, and a completed FDA MedWatch form if requested to support the medical necessity determination.

Denial Risk

Risk of denial if medical necessity not demonstrated

PA requests are reviewed solely to determine medical necessity; lack of required documentation or failure to justify nonpreferred or off‑label use may result in denial of the request.

Clinical and Administrative Context

This form functions as an administrative tool to collect consistent clinical and billing information needed to evaluate PA requests for pharmacy benefits under Anthem programs serving Indiana. It standardizes required data elements so PA reviewers have the diagnosis and billing codes, medication details, prior medication trial history, and recent diagnostic or laboratory results needed to assess medical necessity.

Required elements include a completed form in its entirety (any incomplete sections will delay processing), an ICD-10-CM diagnosis code for all requests, and an HCPCS billing code for medical-administered or oncology requests. The form also captures member demographics and residence, medication name/strength and SIG (dose, frequency, duration), provider and billing facility details (including NPI and DEA/license where applicable), and pharmacy contact information when the pharmacy is the requester.

The form collects documentation of prior medication trials (drug name/strength, date range, SIG, and outcome such as adverse reaction or inadequate response) and directs providers to supply supporting records — for example, copies of medical records, office notes, or a completed FDA MedWatch form — if requested. It also requests diagnostic studies or laboratory test results performed within the past 30 days that pertain to the requested medication or diagnosis.

Providers must fax the completed form and any supporting documentation to 844-864-7860. Reviewers allow at least 24 hours for review, and the pharmacy may dispense up to a 72-hour supply while awaiting the outcome. Approval is based solely on medical necessity and does not guarantee payment, which remains subject to member eligibility, other coverages, and program restrictions.