Alabama Form 369 – Fill Out and Use This PDF

The Alabama 369 form serves a crucial role as the Medicaid Pharmacy Prior Authorization Request Form, guiding both prescribers and pharmacies through the necessary steps to obtain prior authorization for specific medications under the Alabama Medicaid program. Its detailed structure demands information ranging from patient demographics to clinical justifications for the requested drug, ensuring a thorough review process. For those navigating the Alabama Medicaid system, understanding this form's intricacies is paramount.

To ensure your medication requests are processed swiftly and accurately, click the button below to start filling out your Alabama 369 form correctly.

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Alabama Form 369 PDF Details

In the realm of healthcare and medication access within Alabama, the Alabama Medicaid Pharmacy Prior Authorization Request Form, commonly referred to as Form 369, serves a pivotal role. This comprehensive form is designed to streamline the process of obtaining prior approval for specific medications under the Alabama Medicaid program. It encompasses various sections that collect essential information about the patient, including their name, Medicaid number, date of birth, and phone number, as well as whether they reside in a nursing home. The prescriber section requires detailed input from the healthcare provider, such as their name, National Provider Identifier (NPI), license number, and contact information, alongside a certification that the requested treatment is necessary and meets Medicaid's guidelines. The form also delves into the clinical details of the requested drug, including its strength, quantity, diagnosis codes, and the medical justification for its use, emphasizing the importance of thorough documentation in supporting the patient’s need for the medication. Additionally, it categorizes various types of medications and requests specific data on prior drug usage, treatment durations, and justifications for discontinuing any previous medications. The prescribing practitioner is encouraged to provide as much relevant information as possible to justify the medical necessity of the request, showcasing the form's role in ensuring that Medicaid beneficiaries receive medically appropriate and cost-effective treatments. Moreover, dispensing pharmacy information section facilitates the connection between the medication prescriber, the patient, and the pharmacy, underscoring the collaborative effort required to process these requests effectively.

Question	Answer
Form Name	Alabama Form 369
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Alabama, alabama medicaid pa form, contraindication, alabama medicaid prior authorization

Form Preview Example

Street or PO Box /City/State/Zip

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

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

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 www.medicaid.alabama.gov

Alabama Medicaid Agency

Form 369

Revised 7/1/15

www.medicaid.alabama.gov

Page 2

Patient Medicaid #

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		r No
If yes, is treatment plan attached?	r Yes r No
Indicate prior and/or current analgesic therapy and alternative management choices
Drug/therapy			Reason for d/c
Drug/therapy			Reason for d/c

r Antipsychotic Agents	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

kg.

Current weight

kg.

Documentation MD supervised exercise/diet regimen > 6 mo.? r Yes

r No

Planned adjunctive therapy? r Yes

r No

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	Height		inches	Current weight		kg.

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?			r	Yes	r	No
Is the request for chronic idiopathic urticaria?			r	Yes	r	No
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)?			r	Yes	r	No
Has the patient had a positive skin or blood test reaction to a perennial aeroallergen?			r	Yes	r	No
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?			r	Yes	r	No
Are the patient’s baseline IgE levels between 30 IU/mL and 700 IU/mL?			r	Yes	r	No
Level:_________________	Date:__________________

Form 369	Alabama Medicaid Agency
Revised 7-1-15	www.medicaid.alabama.gov

How to Edit Alabama Form 369 Online for Free

Our PDF editor allows you to complete forms. It's not necessary to perform much to change hid forms alabama files. Simply check out the next actions.

Step 1: Choose the button "Get Form Here".

Step 2: The form editing page is now open. You can include text or manage present data.

The PDF file you wish to complete will contain the following areas:

Put the necessary data in the CLINICAL INFORMATION, Strength, Qty, Days supply, PA Refills Other, Drug requested, J Code, If applicable, Diagnosis or ICDICD Code, Diagnosis or ICDICD Code, r Initial Request, r Renewal, r Maintenance Therapy r Acute, Medical justification, and r Additional medical justification box.

It is vital to provide certain particulars within the box Dispensing pharmacy, Phone with area code, NDC, DISPENSING PHARMACY INFORMATION, NPI, Fax with area code, NOTE See Instruction sheet for, and Alabama Medicaid Agency.

You have to describe the rights and obligations of each side in space Page, Patient Medicaid, r Sustained Release Oral Opioid, Is medicine for PRN use r Yes r No, Drugtherapy, Drugtherapy, Reason for dc, Reason for dc, r Antipsychotic Agents The request, and For children years of age have.

Fill in the form by analyzing these fields: r XenicalR, r If initial request Weight kg, inches BMI, kgm, r If renewal request Previous, Current weight, Documentation MD supervised, Planned adjunctive therapy r Yes r, r Phosphodiesterase Inhibitors, Failure or inadequate response to, Contraindication of alternate, r Documentation of vasoreactivity, r Consultation with specialist, r Specialized Nutritionals Height, and If years of age record supports.

Step 3: Once you click on the Done button, the finalized file is conveniently transferable to any type of of your devices. Or, you may send it via mail.

Step 4: Be sure to stay clear of possible future troubles by preparing at least a couple of duplicates of your document.

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