This form must be completed and faxed to the applicable payer source to waive prior authorization (PA) for Buprenorphine for individuals participating in the Addiction Treatment Program (ATP) and eligible for Medicaid. It may take up to 24 hours, from receipt of this form, to waive PA to initiate coverage of the Buprenorphine. If expedited access is necessary, please contact the payer source.

This completed form, for each participant,or a list of all ATP participants, should be faxed or sent via secure email to the applicable payer source to receive enhanced supportive services, such as:

  • Care management services, care coordination, and connection to medical services with panel providers
  • Assistance with transportation to medical appointments
  • Supportive services for socio-economic barriers

Section 1 – Complete for Initiation of Services or When There is a Change in Payer Source

Managed Care Plan Payer: / Member Name:
DOB: / 12-digit Medicaid ID#:
(if known)
Member Address:
Member Telephone #: / Date of Submission:
Prescriber and/ or Treatment Center Name: / Prescriber/Treatment Center Telephone #:
County: / Medication-Assisted Treatment:☐Vivitrol ☐Buprenorphine☐ Methadone ☐None

Section 2 – Complete When Individual Has Change in ATP Participation Status

Member Name: DOB:

The above person is no longer a participant in the MAT Drug Court Program effective: ______.

Payer Source

The attached lists provides contact information for the Medicaid payer sources.

  • Pharmacy fax number: fax this form to waive PA for BuprenorphineOR fax this form or list of ATP participants to receive enhanced supportive services
  • Pharmacy telephone number: to request expedited PA for Buprenorphine.
  • Member Services telephone number: for the member to request enhanced services as ATP participant
  • Send this form or a list of ATP participants, via secure email, to receive enhanced supportive services

Payer Name and Contact Information
Buckeye Health Plan
866-704-3066:ATP fax number
866-246-4356 extension 24187:pharmacy telephone number
866-246-2358: Member Services number
end secure email
CareSource
866-206-0610ATP fax number
800-488-0134 pharmacy telephone number
800-488-0134 Member Services number
and Secure Email
Molina Healthcare of Ohio
800-961-5160ATP fax number
800-642-4168 option 1 then option 2 pharmacy telephone number
855-665-4623 Member Services number
and ecure Email
Paramount Advantage
844-256-2025 fax number
800-891-2520 option 2 then option 1 pharmacy telephone number
800-462-3589 Member Services number
and ecure Email
United Healthcare Community Plan of Ohio
855-633-3306 fax number
517-852-0842 pharmacy telephone number (Back up number is 248-331-4277)
800-707-8194 specialty pharmacy telephone number for Vivitrol® only
800-707-8217 specialty pharmacy fax number for Vivitrol® only
800-600-9007 providers only
877-542-9236 Member Services number
or Secure Email
Medicaid Fee-for-Service
800-396-4111 fax number
614-752-3068 Pharmacy Department number
Secure Email
Medication Assisted Treatment (MAT) Drug Court Program Communication Form / August 2017