Anthem
   
Drug List Addition / Clinical Criteria Change Request Form

                          Please note, all required fields (indicated by an *) must be completed and will be verified for authenticity.

General Request Information

  1. Full Name of requestor:
 
 


2. Are you a Member, Prescriber or
Other
 

If Other please specify

 

3. Requestor's specialty or area of
practice:

 
 


4. Address of requestor:
Street, City, State, Zip Code

 


5. Phone Number

 


6. Email Address

 


7. Please disclose any potential conflicts
of interest:
    I, my spouse, or a dependent, have a financial interest (i.e. shareholder, equity) or of any organizational nature (i.e. employee, president, board member, owner, partner).


Yes    No
    I, have served as a consultant, advisor, speaker, or researcher with the manufacturer. Yes    No
 
 

Drug List Addition

  8. Name of drug being requested
 
  9. Clinical rationale for requested drug
 
  10. Drug List (if known): Essential Drug
List or National Drug List for example

  11. Line of Business (if known):
Commercial, Medicare or Medicaid

 
  12. Drug Name/Therapeutic Class

 

Changes to Clinical Criteria

  13. Clinical Guideline # (if known)

 
  14. Brief description of requested change to clinical criteria
 
 
  15. Provide evidence (e.g. cite peer-reviewed, published literature) to support the addition
of a drug or a change in clinical criteria

 
 

Thank you for your inquiry.

The medications on our drug lists are thoroughly reviewed by our Pharmacy and Therapeutics (P&T) Committee. The P&T Committee includes practicing physicians, pharmacists, and clinicians from leading academic medical centers with expertise in evidence-based medicine. All major clinical specialties are represented. The P&T Committee meets regularly to review which drugs should be added, removed or have changes to the benefit tiers. Their decisions help us create drug lists that improve health outcomes for our members. Your comments are appreciated and we value your input. Your inquiry will be shared with the P&T Committee at its next scheduled meeting.



Close

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem websites constitutes your agreement with our Terms of Use..