The Alabama 369 form is a request form used for prior authorization of pharmacy services under Alabama Medicaid. This form collects essential information about the patient, prescriber, and the medication being requested. It ensures that the prescribed treatments meet the necessary guidelines established by the Alabama Medicaid Agency.
The Alabama 369 form is an essential document used for requesting prior authorization for pharmacy services under the Alabama Medicaid program. This form gathers important information about the patient, including their name, Medicaid number, date of birth, and contact information. It also requires details about the prescriber, such as their name, license number, and contact information, ensuring that the treatment is supervised by a qualified professional. The form is designed to capture clinical information about the medication being requested, including its strength, quantity, and diagnosis codes. Additionally, it differentiates between initial requests, renewals, and maintenance therapy. Supporting documentation is crucial and must be provided to justify the request, especially if the medication has a generic equivalent. The form also includes sections for drug-specific information, allowing prescribers to indicate the type of medication and any previous treatments the patient has undergone. Overall, the Alabama 369 form streamlines the process of obtaining necessary medications for patients while adhering to Medicaid guidelines.
Page 1
Alabama Medicaid Pharmacy
Prior Authorization Request Form
rPage 1 of 1 r Page 1 of 2
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 r Yes
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 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
r Initial Request
r Renewal
r
Maintenance Therapy
r Acute Therapy
Medical justification
r Additional medical justification attached.
Medications received through coupons and samples are not acceptable as justification.
*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
r ADD/ADHD Agents
r Alzheimer’s Agent
r Androgens
r Antidepressants
r Antidiabetic Agent
r Antiemetic Agents
r Antihistamine
r Antihyperlipidemics
r Antihypertensives
r Antipsychotic Agents
r Antiinfective
r Anxiolytics, Sedatives and Hypnotics
r Cardiac Agents
r EENT-Antiallergics
r EENT-Vasoconstrictors
r Estrogens
r H2 Antagonist
r Intranasal Corticosteroids
r Narcotic Analgesics
r NSAID
r Oral Anticoagulants
r Platelet Aggregation Inhibitors
r PPI
r Respiratory Agents
r Skeletal Muscle Relaxants
r Skin & Mucous Membrane Agent r Triptans
r Other
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
If no previous drug usage, additional medical justification must be provided.
DISPENSING PHARMACY INFORMATION
May Be Completed by Pharmacy
Dispensing pharmacy
NDC #
NOTE: See Instruction sheet for specific PA requirements on the Medicaid website at www.medicaid.alabama.gov
Alabama Medicaid Agency
Form 369
Revised 7/1/15
www.medicaid.alabama.gov
Page 2
rSustained Release Oral Opioid Agonist
Proposed duration of therapy
Is medicine for PRN use?
r Yes
r No
Type of pain r Acute r Chronic
Severity of pain: r Mild
r Moderate r Severe
Is there a history of substance abuse or addiction? r Yes
If yes, is treatment plan attached?
r Yes r No
Indicate prior and/or current analgesic therapy and alternative management choices
Drug/therapy
The request is for:
r Monotherapy or r Polytherapy
For children < 6 years of age, have monitoring protocols (see Attachment C on the Alabama Medicaid website) been followed? r Yes r No For polytherapy and/or off-label use, please provide medical justification to support the use of the drug being requested.
Medical justification may include peer reviewed literature, medical record documentation, chart notes with specific symptoms that the support the diagnosis, etc.
rXenicalR
If initial request
Weight
kg.
Height
inches
BMI
kg/m2
If renewal request
Previous weight
Current weight
Documentation MD supervised exercise/diet regimen > 6 mo.? r Yes
Planned adjunctive therapy? r Yes
r Phosphodiesterase Inhibitors
Failure or inadequate response to the following alternate therapies:
1.
2.
3.
4.
5.
6.
Contraindication of alternate therapies:
r Documentation of vasoreactivity test attached
r Consultation with specialist attached
r Specialized Nutritionals
rIf < 21 years of age, record supports that > 50% of need is met by specialized nutrition
rIf > 21 years of age, record supports 100% of need is met by specialized nutrition
Method of administration
Duration
# of refills
r Xolair®
Current Weight:__________kg (patient’s weight must be between 30-150kg)
Is the patient 12 years or older?
Yes
No
Is the request for chronic idiopathic urticaria?
Is the request for moderate to severe asthma and is treatment recommended by a board
certified pulmonologist or allergist after their evaluation (if yes answers questions below)?
Has the patient had a positive skin or blood test reaction to a perennial aeroallergen?
Is the patient symptomatic despite receiving a combination of either inhaled corticosteroid
and a leukotriene inhibitor or an inhaled corticosteroid and long acting beta agonist or has
the patient required 3 or more bursts of oral steroids within the past 12 months?
Are the patient’s baseline IgE levels between 30 IU/mL and 700 IU/mL?
Level:_________________
Date:__________________
Revised 7-1-15
Al Cpt 2023 Instructions - The Alabama 9501 form serves as an application for individuals seeking to register a new business entity within the state.
Real Estate Sales Validation Form - The date of sale is a required field, ensuring the transaction is recorded accurately and timely.
When navigating the complexities of hiring, having access to a reliable employment verification form is crucial for both parties involved. This document assists in confirming essential details such as job title, dates of employment, and reasons for leaving a position. To facilitate this process and ensure accuracy, resources like PDF Templates Online can be incredibly helpful for obtaining the necessary templates.
Car Repossession Laws in Alabama - Designed to certify the lawful repossession of a vehicle due to a breach in the lien or security agreement.