CurrentBlue Cross Blue Shield - MainePolicy N/A

Pharmacy Prior Authorization Form — Coverage Criteria

Form and instructions to request prior authorization for medications (including medical injectables/oncology) for members in Anthem Blue Cross and Blue Shield Indiana programs; intended for prescribers, pharmacies, and billing facilities to submit PA requests. Payment remains subject to member eligibility, other health insurance, and program restrictions.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPharmacy Prior Authorization Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with an ICD-10-CM diagnosis code (and HCPCS code for injectables/oncology) via fax to 844-864-7860.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72-hourpharmacy may dispense supply while awaiting PA decision

24 hoursminimum review time allowed for PA request

844-864-7860fax number to send completed form

ICD-10-CM requireddiagnosis code required for all requests

HCPCS required for injectables/oncologybilling code requirement

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPharmacy Prior Authorization Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with an ICD-10-CM diagnosis code (and HCPCS code for injectables/oncology) via fax to 844-864-7860.

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 Criteria

Complete the form in its entirety — incomplete sections will result in a delay in processing. Requests for prior authorization are reviewed only for medical necessity. Approval of a prior authorization does not guarantee payment; payment remains subject to current member eligibility, other health insurance, and applicable program restrictions. Submit the completed form via fax to 844-864-7860 and allow at least 24 hours for review. The pharmacy may dispense up to a 72-hour supply while awaiting the outcome of the request.

Required Coding

Required codingmixed

ICD-10-CM	Diagnosis code required for all requests
HCPCS	Billing code required for all medical injectable/oncology requests

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required. An ICD-10-CM diagnosis code is required for all requests. An HCPCS billing code is required for all medical injectable/oncology requests. If the billing facility is different from the requesting physician, billing facility information must be completed. Fax completed forms and required information to 844-864-7860. Allow at least 24 hours for review; approvals are made only for medical necessity and payment remains subject to member eligibility and other program rules. We will notify you and the member's pharmacy of our decision.

ICD-10-CM diagnosis code required for all requests
HCPCS billing code required for medical injectable/oncology requests
Fax to 844-864-7860
Allow at least 24 hours for review

Denial Risk

Complete All Sections

Complete the form in its entirety. Any incomplete sections will result in a delay in processing. Requests are reviewed only for medical necessity; payment remains subject to all general conditions of Blue Cross Blue Shield - Maine, including current member eligibility and other insurance or program restrictions.

Incomplete sections will delay processing
Approval does not guarantee payment — subject to eligibility and program rules

Documentation Required

Supporting Documentation May Be Requested

You may be asked to provide supporting documentation to substantiate medical necessity. Acceptable documentation may include copies of medical records, office notes, and a completed FDA MedWatch form when applicable. Provide these materials with the PA request to expedite review.

Copies of medical records
Office notes
Completed FDA MedWatch form (if applicable)

Billing Rule

Required Form Fields

The form requires member demographics, administration site, height/weight, medication details (drug name, strength, SIG, dose/frequency/duration), ICD-10-CM diagnosis code, and HCPCS billing code for applicable requests. If the billing facility differs from the requesting physician, include billing facility information.

Member name, Member ID, Date of birth, Sex, Place of residence
Administration site (home, office, outpatient facility)
Height and weight
Drug name and strength, SIG (dose, frequency, duration)
ICD-10-CM diagnosis code (required)
HCPCS billing code (required for medical injectable/oncology)
Billing facility information if different from requesting physician

Step Therapy

Prior Medication Trial Documentation

The form asks whether the member has tried other medications to treat the condition and requests details of prior medication trials. If yes, provide drug name and strength, date range of use, SIG (dose and frequency), and reason for discontinuation (adverse reaction, inadequate response, or other) with brief details. You may be asked to provide supporting documentation for prior trials.

Indicate if member tried other medications and provide details
Drug name/strength, date range of use, SIG
Document adverse reaction, inadequate response, or other reason
Supporting documentation (medical records, office notes) may be requested

Site of Care

Note

Specify administration site

Indicate the administration site on the form by selecting the appropriate setting: Home, Office, Outpatient facility, or Nursing facility.

Administration site is recorded in the Member information section of the form.