Get Amerigroup Pharmacy Prior Authorization Form 2019-2025

Filling out the Amerigroup Pharmacy Prior Authorization Form online is a crucial step in ensuring timely access to necessary medications. This guide provides clear instructions to help users navigate the form effectively and efficiently.

Follow the steps to complete the form accurately and submit your request.

1. Click the ‘Get Form’ button to obtain the Amerigroup Pharmacy Prior Authorization Form and open it in your preferred editor.
2. Begin by filling out the member information section. This includes entering the last name, first name, middle initial, Amerigroup ID number, date of birth, height, and weight.
3. Indicate the member’s place of residence, selecting either 'Home' or 'Nursing facility', as well as the administration site which can be 'Home', 'Office', or 'Outpatient facility'.
4. In the medication information section, provide the requested drug name and strength, and fill in the SIG, which includes dose, frequency, and duration.
5. Enter the diagnosis and/or indication for the medication, as well as any previous medications tried for this condition.
6. Include the HCPCS billing code and the required ICD code for all requests.
7. If applicable, provide details about any adverse reactions or inadequate responses the member may have experienced with other medications.
8. Detail the medical necessity for any non-preferred medications or prescribing outside of FDA labeling.
9. List all current medications the member is taking, including dose and frequency.
10. Complete the diagnostic studies and/or laboratory tests section, listing all related tests done within the past 30 days.
11. Fill out the prescriber information including last name, first name, NPI number, DEA/license number, address, contact number, and the office contact name.
12. If billing facility information is separate from the prescriber, ensure to fill that out as well.
13. Provide the pharmacy information, including name, NPI number, and contact details.
14. Review the form for completeness before signing. The prescriber must certify that the information is accurate and complete.
15. Finally, save your changes and download or print the completed form as needed for your records.

Start filling out the Amerigroup Pharmacy Prior Authorization Form online today to ensure your medications are approved without delay.