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Anthem Blue Cross : Pre-Service Medical Review for Specialty Drugs

Pre-Service Medical Review for Specialty Drugs

In response to your concerns about unique billing requirements and retrospective medical review for specialty drugs, Anthem Blue Cross offers pre-service medical review in an effort to speed payment to providers and to help monitor the appropriateness of the dose and frequency of specialty drugs for our members.  
We have implemented Pre-Service Medical Review of Specialty Drugs that are provided under a member’s medical benefits.  
The pre-service medical review program has three goals:  
Review dose and frequency of specialty drugs
Pre-identify members for case management
Eliminate provider abrasion by helping decrease claims processing time
This important aspect of our Utilization Management (UM) review process could directly affect how you get paid for rendering services to our members.  
While you are not required to use this process, your claims will continue to be subjected to the current retrospective medical review process if you do not receive pre-service review approval.  
Click the following links for:  
A List of Specialty Drugs that Require Pre-Auth
Pre-Service Medical Review Request Form
Frequently Asked Questions and Answers
Note: Pre-service medical review is applicable for Anthem Blue Cross’ PPO members. Additionally, select members may not require pre-service medical review depending on their elected benefits. Please see the FAQ link above for more specific information. For additional information, please call our UM department at 800-274-7767.  
How do I obtain a pre-authorization? 
Download the pre-service review form for the medication being requested.
Complete the form in its entirety and attach all necessary supporting information, e.g. labs, notes, etc.
Fax the completed form and all supporting information to 866-408-7195.  

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.