Pharmacy Prior Authorization Form — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
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
| 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 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
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
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)
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
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
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.
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