CurrentAnthemPolicy N/A

Pharmacy Prior Authorization Form

Form and instructions for requesting prior authorization for pharmacy and medical injectable medications for Anthem HealthKeepers Plus Medicaid members; intended for prescribing providers, billing facilities, and pharmacies serving these members.

Policy Summary

PayerAnthem

PolicyPharmacy Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form and required documentation with ICD and HCPCS codes to the appropriate number to request prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24hmin review turnaround

72-hourtemporary dispense allowance

2fax numbers provided

1ICD required

HCPCSHCPCS required (injectables)

Coverage and Authorization Criteria

General prior authorization criteria

Coverage decisions are based on medical necessity using information submitted on this form and supporting documentation.

Submission completeness: Form completed in its entirety

Incomplete sections on the form will result in a delay in processing and may lead to denial

Coding provided: ICD/diagnosis code provided for all requests; HCPCS code provided for medical injectable/oncology requests when applicable

If the billing facility is different from the requesting physician, billing facility information must be completed

Clinical justification: Medication history, prior treatment failures or adverse reactions, and diagnostic/lab tests documented to justify nonpreferred medication or prescribing outside FDA labeling

Supporting documentation (eg, medical records, office notes, FDA MedWatch forms, and diagnostic/lab tests within past 30 days) may be requested

Policy Summary

PayerAnthem

PolicyPharmacy Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form and required documentation with ICD and HCPCS codes to the appropriate number to request prior authorization.

SourceLink

On This Page

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.

Coverage decisions are made based on medical necessity using the information submitted on this form and any supporting documentation. Approval of a prior authorization request does not guarantee payment; payment remains subject to member eligibility, other insurance, and program restrictions. Providers should complete the form fully and include required coding — an ICD/diagnosis code is required for all requests, and an HCPCS billing code is required for medical injectable/oncology requests when applicable. Fax completed requests to the appropriate number: 844-512-7020 for retail pharmacy or 844-512-7022 for medical injectables.

Required Codes and Key Timing

Required billing codes for injectablesHCPCS

HCPCS

HCPCS billing code required for all medical injectable/oncology requests

Required diagnosis codesICD-10

ICD	ICD/diagnosis code required for all requests

Review time

Minimum review turnaround time>= 24 hours (allow at least 24 hours for review)

Temporary dispense allowancePharmacy may dispense up to a 72-hour supply while awaiting decision

Fax submission numbersFax required information to 844-512-7020 (retail) or 844-512-7022 (medical injectables)

Contact for questionsAnthem HealthKeepers Plus Provider Services: 800-901-0020

Approval and payment caveatApproval is based on medical necessity; payment remains subject to member eligibility, other insurance, and program restrictions

Provider Submission Requirements and Risks

Prior Authorization

Submission and coding requirements

An ICD/diagnosis code must be provided for all prior authorization requests. For medical injectable or oncology requests, include the HCPCS billing code. If the billing facility differs from the requesting physician, complete the billing facility information. Fax completed requests to 844-512-7020 for retail pharmacy or 844-512-7022 for medical injectables.

ICD/diagnosis code required for all requests.
HCPCS billing code required for medical injectable/oncology requests.
Fax to 844-512-7020 (retail) or 844-512-7022 (medical injectables).

Step Therapy

Prior medication history details required

If the member has tried other medications for the condition, provide the drug name and strength, date range of use, SIG (dose and frequency), and outcome (adverse reaction, inadequate response, or other).

Drug name and strength
Date range of use
SIG (dose and frequency)
Outcome: adverse reaction, inadequate response, or other

Documentation Required

Provide supporting documentation on request

Be prepared to submit supporting clinical documents if requested. Examples include copies of medical records, office notes, complete FDA MedWatch forms, and diagnostic or laboratory test results performed within the past 30 days related to the requested medication.

Copies of medical records and office notes
Completed FDA MedWatch form
Diagnostic studies and laboratory tests performed within the past 30 days

Denial Risk

Risk of delay or denial for incomplete form

Complete the form in its entirety; any incomplete sections will result in a delay in processing and may lead to denial or a delayed prior authorization decision.

Incomplete sections delay processing and may lead to denial

Purpose of the Prior Authorization Form

This form collects the clinical and administrative details needed to support prior authorization decisions for pharmacy and medical injectable medications for Anthem HealthKeepers Plus members. It requests medication name and strength, dosing instructions, diagnostic/ICD codes, HCPCS billing codes (for injectables), medication history, and any relevant labs or diagnostic tests to document medical necessity.

Complete every section of the form; incomplete sections will result in a delay in processing and may lead to denial or delayed authorization. Allow at least 24 hours for review. While awaiting a decision, the pharmacy may dispense up to a 72-hour supply per the instructions on the form.

Administration Site Options

Note

Specify home administration site

Indicate on the form if the medication will be administered at the member's home by checking the 'Home' administration site box.

Select 'Home' under Administration site when applicable.

Note

Specify office administration site

Indicate on the form if the medication will be administered in the provider's office by checking the 'Office' administration site box.

Select 'Office' under Administration site when applicable.

Note

Specify outpatient/infusion center administration site

Indicate on the form if the medication will be administered in an outpatient infusion facility by checking the 'Outpatient facility' administration site box.

Select 'Outpatient facility' under Administration site when applicable.

OpenPayer

Pharmacy Prior Authorization Form

Coverage and Authorization Criteria

Required Codes and Key Timing

Provider Submission Requirements and Risks

Purpose of the Prior Authorization Form

Definitions and Request Types

Administration Site Options