CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Prior Authorization for Brand Medically Necessary (BMN) Medication

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.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPrior Authorization for Brand Medically Necessary (BMN) Medication

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the BMN prior authorization form with all sections completed and attach a photocopy of the FDA MedWatch form describing the adverse event experienced with the generic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2fax numbers provided for PA submission (retail and injectable)

4provider help desk phone lines listed (by program)

1requirement to attach an FDA MedWatch form

1reference to Indiana Medicaid regulation requiring PA for BMN

Coverage Criteria for Brand Medically Necessary (BMN)

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 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.

Provider Submission Requirements and Support

Prior Authorization

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

Note

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

Brand Medically Necessary (BMN) — definition and context

DefinitionSpecifying a brand-name drug as medically necessary when a substitutable generic is available; requires prior authorization under Indiana Medicaid per 405 IAC 5-24-8(a).

Who must complete formForm must be completed by the prescribing provider (prescriber).

Documentation requiredA completed FDA MedWatch form describing the adverse event(s) with the generic equivalent must be attached to the PA request.

Regulatory basisIndiana Medicaid regulation: 405 IAC 5-24-8(a) requires prior authorization when specifying brand medically necessary for substitutable brand drugs.

Programs coveredApplies to Anthem Blue Cross and Blue Shield programs serving Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging.