Alabama Medicaid Pharmacy Prior Authorization Request Form

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Alabama Medicaid Pharmacy
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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 36823-3210
PATIENT INFORMATION
Patient name
Patient Medicaid #
Patient DOB
Patient phone # with area code
Nursing home resident
Yes
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PRESCRIBER INFORMATION
Prescriber name
NPI #
License #
Phone # with area code
Fax # with area code
Address (Optional)
Street or PO Box /City/State/Zip
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 Practitioner Signature
Date
CLINICAL INFORMATION
Drug requested*
Strength
J Code
Qty.
Days supply
PA Refills: 0 1 2 3 4 5 Other
If applicable
Diagnosis or ICD-9/ICD-10 Code
Diagnosis or ICD-9/ICD-10 Code
Initial Request
Renewal
Maintenance Therapy
Acute Therapy
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Medical justification
Additional medical justification attached.
Medications received through coupons and samples are not acceptable as justification.
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*If the drug being requested 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.
DRUG SPECIFIC INFORMATION
ADD/ADHD Agents
Alzheimer’s Agent
Androgens
Antidepressants
Antidiabetic Agent
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Antiemetic Agents
Antihistamine
Antihyperlipidemics
Antihypertensives
Antipsychotic Agents
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Antiinfective
Anxiolytics, Sedatives and Hypnotics
Cardiac Agents
EENT-Antiallergics
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EENT-Vasoconstrictors
Estrogens
H2 Antagonist
Intranasal Corticosteroids
Narcotic Analgesics
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NSAID
Oral Anticoagulants
Platelet Aggregation Inhibitors
PPI
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Respiratory Agents
Skeletal Muscle Relaxants
Skin & Mucous Membrane Agent
Triptans
Other
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List previous drug usage and length of treatment as defined in instructions for drug class requested.
Generic/Brand/OTC
Reason for d/c
Therapy start date
Therapy end date
Generic/Brand/OTC
Reason for d/c
Therapy start date
Therapy end date
If no previous drug usage, additional medical justification must be provided.
DISPENSING PHARMACY INFORMATION
May Be Completed by Pharmacy
Dispensing pharmacy
NPI #
Phone # with area code
Fax # with area code
NDC #
NOTE:
See Instruction sheet for specific PA requirements on the Medicaid website at
Form 369
Alabama Medicaid Agency
Revised 7/1/15

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