Prior Authorization for Brand Medically Necessary (BMN) Medication
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Governs prior authorization requests when a prescriber specifies 'brand medically necessary' for substitutable brand-name drugs for Anthem Blue Cross and Blue Shield members in Indiana Medicaid programs; applies to prescribing providers completing the BMN PA form.
No material clinical or coverage changes in this revision.
Coverage Criteria for Brand Medically Necessary (BMN)
Coverage conditions for BMN requests
Coverage of a brand medication when marked BMN is contingent on prior authorization and submission of documentation.
ALL of the following
ALL of the following
ALL of the following
- The PA form must be completed by the prescribing provider and include prescriber details and signature.
ALL of the following
- All sections of the PA form must be completed or the request will be returned.
ALL of the following
ALL of the following
- A photocopy of the completed FDA MedWatch form describing adverse event(s) with the generic equivalent must be attached to the PA request. Do not submit original MedWatch forms to Anthem.
ALL of the following
ALL of the following
- Retroactive PA requests (dates of service prior to eligibility determination) must be submitted separately from current PA requests; include dates of service when applicable.
Regulatory and Coding Citations
| 405 IAC 5-24-8(a) | Indiana Medicaid regulation requiring prior authorization when specifying brand medically necessary for substitutable brand drugs |
Provider Submission Requirements and Support
Prior Authorization Required
Prescriber must complete the BMN prior authorization form. All sections are required — if any section is incomplete the request will be returned. The form must be completed by the prescribing provider and include patient identifiers (Medicaid #, name, date of birth), prescriber information (name, IN license #, specialty, NPI, signature, return fax and phone), and indicate if retroactive PA is requested with dates of service. Providers contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging through an ACO, PMG or IPA must follow their group's authorization and claims practices. Prior authorization is contingent upon submission to the FDA of a completed MedWatch form describing the adverse event(s) experienced with the generic equivalent; attach a photocopy (do not send originals).
- Complete and fax form to Prior Authorization of Benefits Center: 844-864-7860 (retail) or 888-209-7838 (medical injectable)
- All sections must be completed or the request will be returned
- If requesting retroactive PA, mark box and provide dates of service requested
- Attach photocopy of MedWatch form submitted to FDA; do not submit originals
- MedWatch form download: http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM163919.pdf
Support Contacts
For assistance with prior authorization submissions, eligibility questions, or help completing required forms, contact the Provider Help Desk or program-specific numbers below. Submit retroactive PA requests (dates of service prior to eligibility determination) separately from current PA requests per instructions.
- Provider Help Desk (general): 866-408-6132
- Hoosier Healthwise: 866-408-6132
- Healthy Indiana Plan: 844-533-1995
- Hoosier Care Connect: 844-284-1798
- Indiana PathWays for Aging: 833-569-4739
- Prior Authorization fax (retail): 844-864-7860
- Prior Authorization fax (medical injectable): 888-209-7838
Definitions
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