Anthem Prior Authorization/Non-Formulary Exceptions Request Forms

PRIOR AUTHORIZATIONTION / NON-FORMULARYEXCEPTIONS REQUEST FORMfor Anthem Pharmacy ProgramsDate:Physician Telephone Number:Physician FAX Number:Requesting Physician Name and Address: Member ID #:Group ID #:Member (Patient) Name and Address:Medication Requested:Diagnosis:Reason for Request:Have other formulary products been used to treat this patient’s condition? Yes NoIf yes, please list:If no, state reason:Physician’s signature:For Anthem Prescription Management Use OnlyDate Received:Information Reviewed By:Recommendations: one time use only maintenance useComments:Return to:Anthem Prescription Prior Authorization Center8990 Duke Blvd., MP2-826Mason, OH 45040Fax: 800-601-4829Phone: 1-800-338-6180PLEASE COPY THIS FORM FOR FUTURE REQUESTSN678Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.®Registered marks of the Blue Cross and Blue Shield Association.