The Alabama 409 form is a request used for obtaining pharmacy overrides from the Alabama Medicaid Agency. This form allows healthcare providers to submit necessary information to ensure patients receive the medications they require, even when standard limits might apply. By completing this form, prescribers can advocate for their patients' needs effectively.
The Alabama 409 form plays a crucial role in the Medicaid process, particularly for those seeking pharmacy overrides. Designed to facilitate communication between healthcare providers and the Alabama Medicaid Agency, this form is essential for ensuring that patients receive the medications they need in a timely manner. When filling out the form, healthcare professionals must provide detailed patient information, including the patient's name, Medicaid number, and date of birth. Additionally, prescribers are required to supply their own credentials, including their license and NPI numbers, along with contact information. The form also addresses specific clinical situations, such as early refills, maximum unit requests, and therapeutic duplications. Each section prompts the prescriber to justify the need for the requested override, ensuring that all treatments are medically necessary and compliant with Medicaid guidelines. By following the instructions for submission—whether by fax or mail—providers can efficiently navigate the approval process, ultimately enhancing patient care and access to necessary medications.
This form can be filled out while viewing in Adobe Acrobat Reader. Then print it and fax or mail to HID
Alabama Medicaid Pharmacy
Override 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
Nursing home resident ❒ Yes
PRESCRIBER INFORMATION
Prescriber name
License #
NPI #
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
DISPENSING PHARMACY INFORMATION
Dispensing pharmacy
NDC #
J Code
Qty. requested per month
CLINICAL INFORMATION
❒
Early Refill
❒ Maximum Unit/Maximum Cost
Therapeutic Duplication
❒ Brand Limit Switch Over
Requested drug name
Strength
Date of request
For Early Refill
Medication lost
❒ Physician changed the dosage
Medication destroyed
❒ Medication stolen
❒Patient going out of town for period greater than the day’s supply remaining of the previous refill.
Documentation
❒ Supporting Documentation Attached
For Maximum Unit or Maximum Cost
Diagnosis
Medical Justification
For Therapeutic Duplication or ◆Brand Limit Switch Over
Reason for Request
❒ Strength/Dosage change*
❒ Switch over
Titration and Concomitant Therapy**
❒ Drug name
NDC
Qty.
Stop date
if applicable
Reason for change
* Stop date is required for strength/dosage change or switch over.
❒ Medical justification attached
**Attach medical justification if both drugs are to be continued (titration/concomitant therapy). ◆ For specific documentation requirement, see Override instructions on the Medicaid web site.
FOR HID USE ONLY
❒ Approve request
❒ Deny request
❒ Modify request
❒ Medicaid eligibility verified
Comments
Reviewer’s Signature
Response Date/Hour
Form 409
Alabama Medicaid Agency
Revised 2/23/08
www.medicaid.alabama.gov
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