Amerigroup Authorization Request – Fill Out and Use This PDF

Amerigroup Authorization Request PDF Details

The Amerigroup Authorization Request form is required for Ohio Medicaid Managed Care Pharmacy Prior Authorization. It covers medication requests across several managed care plans, including Amerigroup, Buckeye Community Health Plan, CareSource Ohio, MolainaCare Ohio, Paramount Advantage, and UnitedHealthcare Community Plan.

Required Information

The form has four main sections to complete:

• Patient information: full name, date of birth, member ID, and known allergies
• Prescriber details: provider name, NPI number, office contact, and fax number
• Medication specifics: drug name, strength, dosage, directions, quantity, and refill count
• Clinical rationale: diagnosis code, previous treatments tried, and supporting documentation

How to Submit

After completing all sections, fax the form to the managed care plan listed on the form. Each plan has a different fax number. Standard prior authorization requests are typically reviewed within 24 to 72 hours. Urgent requests may receive a faster decision.

Tips for Faster Approval

• Include all required clinical documentation with the initial submission
• Double-check the member ID and plan name before faxing
• Use the correct fax number for the patient's specific managed care plan
• Keep a copy of the completed form for your records