Anthem blue cross blue shield prior authorization form medication

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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Always check benefits through the Voice Response Unit (VRU) or My Insurance ManagerSM to determine if prior authorization is required.

Many of our plans require prior authorization for certain procedures and durable medical equipment. This process allows us to check ahead of time whether services meet criteria for coverage by a member’s health plan.

In many cases, approval is instant. When it’s not, we’ll review your request, taking into account:

• Our medical policies
• Recognized clinical guidelines
• Out-of-area patients (BlueCard®)
• The terms of the member’s benefit plan

Some requests may require additional documentation.

Prior authorization for medical services

When you request prior authorization from us, we want the process to be fast, easy and accurate. We offer these convenient options:

• Medical Forms Resource Center (MFRC) – This online tool makes it easy to submit prior authorization requests for certain services. The tool guides you through all of the forms you need so you can avoid follow-up calls for additional information. 
• My Insurance Manager – You also can submit prior authorization using the same online self-service provider tool you can use to check eligibility, manage claims and more. 
• Fax – If you would prefer to submit your request by fax, complete and follow the submission directions on this form:
  • Precertification Request Form

Prior authorization for behavioral health services

A few plans may continue to require prior authorization for behavioral health services to include applied behavioral analysis (ABA) therapy. To request prior authorization, contact Companion Benefits Alternatives (CBA) using one of the below options:

• Calling 800-868-1032
• Forms Resource Center – This online tool makes it easy for behavioral health clinicians to submit behavioral health prior authorization requests. The tool guides you through all of the forms you need so you can avoid follow-up calls for additional information.

CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueCross.

Prior authorization requirements for out-of-area Blue Plan members

Find medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.

Find requirements

Updated June 02, 2022

An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient’s prescription cost. The form contains important information regarding the patient’s medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patient’s health care plan. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request.

• Contact Anthem
• Specific Anthem Medications

How to Write

Step 1 – At the top of the form, supply the plan/medical group name, plan/medical group phone number, and plan/medical group fax number.

Step 2 – In “Patient Information”, provide the patient’s full name, phone number, full address, date of birth, sex (m/f), height, and weight. Also, specify any allergies and give the name and phone number of the patient’s authorized representative (if applicable).

Step 3 – In “Insurance Information”, provide the primary and secondary insurance providers along with the corresponding patient ID numbers.

Step 4 – In “Prescriber Information”, specify the prescriber’s full name, speciality, and full address. Below that, write the name of the requester (if different than the prescriber) and supply the prescriber’s NPI number and DEA number. Lastly, give the name of an office contact person along with the corresponding phone number, fax number, and email address.

Step 5 – In “Medication / Medical and Dispensing Information”, specify the medication name and indicate whether or not the request is a new therapy or a renewal (if renewal, specify the date therapy started and the duration).

Step 6 – In “Medication / Medical and Dispensing Information”, describe how the patient paid for their medication (include the insurance name and prior authorization number).

Step 7 – In “Medication / Medical and Dispensing Information”, specify the following prescription details: dose/strength, frequency, length of therapy/number of refills, and quantity.

Step 8 – In “Medication / Medical and Dispensing Information”, indicate the administration method and administration location.

Step 9 – At the top of page 2, provide the patient’s name and ID number.

Step 10 – On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. If yes, provide the medication name, dosage, duration of therapy, and outcome.

Step 11 – On page 2 (2), list all diagnoses and provide the ICD-9/ICD-10.

Step 12 – On page 2 (3), provide any details supporting the request (symptoms, clinic notes, lab results, etc.).

Step 13 – The prescriber must provide their signature at the bottom of the form and the date of signing.