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Pharmacy Prior Authorization Form - Anthem

Pharmacy Prior Authorization form HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. VABCBS-CD-008368-22 Revised: November 2022 CCPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, : this form in its entirety. Any incomplete sections will result in a delay in review requests for Prior Authorization based on medical necessity only.

3. To help us expedite your authorization requests, please fax all the information required on this form to 1-844-512-7020 for retail pharmacy or 1-844-512-7022 for medical injectables. 4. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request, call us at 1-800-901-0020.

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