Form 470 - Alabama Medicaid Pharmacy Smoking Cessation Prior Authorization Form

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Alabama Medicaid Pharmacy
Smoking Cessation
Prior Authorization Request Form
FAX: (800) 748-0116
Fax or Mail to
P.O. Box 3210
Phone: (800) 748-0130
Health Information Designs
Auburn, AL 36832-3210
PATIENT INFORMATION
Patient Name ____________________________________________________ Patient Medicaid # ________________________________
Patient DOB ______________________________________
Patient Phone # with area code ____________________________________
PRESCRIBER INFORMATION
Prescriber Name_______________________________________________ NPI # ____________________ License # ____________________
Phone # with area code ___________________________________ Fax # with area code __________________________________________
Address (optional) ____________________________________________________________________________________________________
I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the
Alabama Medicaid Agency. I will be supervising the patient’s treatment. Supporting documentation is available in
the patient record.
_____________________________________________________________________
Prescribing Provider
Date
DRUG/CLINICAL INFORMATION
Drug requested* __________________________________________
Strength _____________________________________
Drug Code ____________________________
Qty. per month ___________________
Days supply __________________________
 Initial Request
 Renewal Request
Duration of therapy __________________________________________________________
A copy of the Department of Public Health’s Alabama Tobacco Quitline Patient Referral/Consent Form signed by the recipient must be submitted
to the Quitline. Additionally, a copy of the Consent Form must be submitted along with this Prior Authorization Request form to Health
Information Designs for approval. The form can be found at
Only one quit attempt will be approved per calendar year.
Plan First Recipients do not require prior approval for smoking cessation products. The Smoking Cessation Prior Authorization Request Form
should not be submitted for those recipients.
*If the requested drug is a brand name drug with an exact generic equivalent available, the FDA MedWatch Form 3500 must be submitted to
HID in addition to the PA Request Form.
DISPENSING PHARMACY INFORMATION
May Be Completed by Pharmacy
Dispensing Pharmacy _________________________________________________________________ NPI # ________________________
Phone # with area code ____________________________________ Fax # with area code _______________________________________
Form 470
Alabama Medicaid Agency
Effective 12/9/13

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