Alabama Medicaid Pa Details

Alabama Form 369 is an income tax form used by Alabama taxpayers to report their state income tax liability. The form is three pages long, and consists of sections for your name, address, and other identifying information; your federal adjusted gross income (AGI); your Alabama taxable income; and your state taxes owed. There are also lines for subtracting any credits you may be eligible for, and for calculating your total payment amount. The form must be filed by April 15th each year. If you're filing a Form 369 for the first time, or if you need help completing it, the Alabama Department of Revenue has a number of resources available on their website.

Below is the information regarding the file you were in search of to complete. It can show you the time you will require to finish alabama form 369, what parts you will have to fill in and a few additional specific details.

QuestionAnswer
Form NameAlabama Form 369
Form Length2 pages
Fillable?Yes
Fillable fields170
Avg. time to fill out34 min 34 sec
Other namesIU, RemicadeR, alabama medicaid pa form, PRESCRIBER

Form Preview Example

This form can be filled out while viewing in Adobe Acrobat Reader. Then print it and fax or mail to HID.

Page 1

Alabama Medicaid Pharmacy

Prior Authorization Request Form

Page 1 of 1

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

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

 

 

 

 

 

 

CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug requested*

 

 

 

 

 

 

 

Strength

J Code

Qty.

 

Days supply

 

PA Refills: 0

 

If applicable

 

 

 

 

 

 

 

 

1 2 3

4

5 Other

Diagnosis or ICD-9 Code

Initial Request

Medical justification

 

Diagnosis or ICD-9 Code

Renewal

 

 

 

Maintenance Therapy

 

 

Acute Therapy

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

ADD/ADHD Agents Alzheimer’s Agent

Antihistamine Antihyperlipidemics

Anxiolytics, Sedatives and Hypnotics

Estrogens

H2 Antagonist

 

 

 

 

Platelet Aggregation Inhibitors

Skin & Mucous Membrane Agent

Antidepressants

Antihypertensives

Cardiac Agents

Intranasal Corticosteroids

PPI

Triptans

Antidiabetic Agent

Antiinfective

EENT-Antiallergics

Narcotic Analgesics

Respiratory Agents

Other

Antiemetic Agents

EENT-Vasoconstrictors

NSAID

Skeletal Muscle Relaxants

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

Form 369

Alabama Medicaid Agency

Revised 4/9/08

www.medicaid.alabama.gov

Page 2

Patient Medicaid #

 

 

 

Sustained Release Oral Opioid Agonist

 

 

Proposed duration of therapy

 

Is medicine for PRN use?

Type of pain Acute Chronic

Severity of pain: Mild Moderate

Is there a history of substance abuse or addiction? Yes

No

 

If yes, is treatment plan attached? Yes

No

 

 

Indicate prior and/or current analgesic therapy and alternative management choices

 

Drug/therapy

 

Reason for d/c

 

Drug/therapy

 

Reason for d/c

 

Yes

Severe

 

No

Biological Injectables

RemicadeR

EnbrelTM

KineretTM

HumiraTM

RaptivaTM

AmeviveR

OrenciaR

 

 

 

 

 

Current weight

kg.

If rheumatoid arthritis, juvenile rheumatoid arthritis or ankylosing spondylitis, is therapy

 

 

approved by a board certified rheumatologist?

 

Yes

 

 

 

 

 

 

 

Prior and/or current DMARD therapy?

Yes

No If yes, attach documentation.

 

 

 

 

 

If Crohn’s disease, is therapy approved by a board certified gastroenterologist?

 

Yes

 

 

 

If RemicadeR is requested for rheumatoid arthritis, will patient be on Methotrexate?

 

Yes

If no, contraindication to use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If plaque psoriasis, is therapy approved by a board certified dermatologist?

Yes

If psoriatic arthritis, is therapy approved by a board certified dermatologist or rheumatologist?

No

No No

No

Yes

No

For Raptiva, Amevive or Enbrel

 

 

 

 

 

Is the patient 18 years of age or older?

Yes

No

 

 

 

Is the patient with chronic moderate to severe plaque psoriasis a candidate for systemic therapy or phototherapy? Yes

No

Has the patient failed 6 month treatment trials with topicals, generic OTC or brand, within the past year?

Yes No

XenicalR

If initial request

Weight

 

 

kg.

Height

 

 

 

Previous weight

 

 

kg.

If renewal request

 

 

 

 

 

 

 

 

 

 

 

 

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

 

inches

BMI

kg/m2

 

 

Current weight

 

kg.

 

 

 

Yes No

Planned adjunctive therapy?

Yes

No

Phosphodiesterase Inhibitors

Failure or inadequate response to the following alternate therapies:

 

 

1.

 

 

 

2.

 

3.

 

4.

 

 

 

5.

 

6.

 

7.

 

 

 

8.

 

9.

 

Contraindication of alternate therapies:

 

 

 

 

 

Documentation of vasoreactivity test attached

Consultation with specialist attached

Specialized Nutritionals

Height

 

inches

Current weight

 

kg.

 

 

 

 

 

 

 

 

 

 

If < 21 years of age, record supports that > 50% of need is met by specialized nutrition

If > 21 years of age, record supports 100% of need is met by specialized nutrition

 

 

Method of administration

 

Duration

 

 

# of refills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XolairR

 

 

Current

weight

 

 

 

 

kg.

 

 

Is treatment recommended by a board certified pulmonologist or allergist after their evaluation?

 

 

 

 

No

 

 

 

 

 

 

 

 

Yes

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?

Yes

No

Has the patient had a positive skin or blood test reaction to a perennial aeroallergen?

 

 

Yes

No

Is the patient 12 years of age or older?

 

 

Yes

No

Are the patient’s baseline IgE levels between 30 IU/ml and 700 IU/ml?

 

 

 

 

Yes

No

Level:

 

Date:

 

 

 

 

 

 

Is the patient’s weight between 30 and 150 kg?

Yes

No

FOR HID USE ONLY

Approve request Comments

Deny request

Modify request

Medicaid eligibility verified

Reviewer’s Signature

Response Date/Hour

Form 369

Alabama Medicaid Agency

Revised 4/9/08

www.medicaid.alabama.gov

How to Edit Alabama Form 369

Having the objective of allowing it to be as simple to operate as possible, we set up our PDF editor. The process of filling in the alabama medicaid prior authorization phone number is going to be straightforward in case you try out the following steps.

Step 1: Initially, press the orange button "Get Form Now".

Step 2: Now you're on the document editing page. You may modify and add text to the file, highlight specified content, cross or check particular words, add images, sign it, erase unnecessary fields, or remove them entirely.

Fill out all of the following segments to fill out the template:

entering details in eent stage 1

You have to note the necessary details in the J Code, Qty, If applicable, Diagnosis or ICD-9 Code, Days supply PA Refills: 0 1 2 3 4, Diagnosis or ICD-9 Code, ❒ Initial Request, ❒ Renewal, ❒ Maintenance Therapy ❒ Acute, Medical justification, ❒ Additional medical justification, Medications received through, *If the drug being requested is a, DRUG SPECIFIC INFORMATION, ❒ ADD/ADHD Agents ❒ Alzheimer’s, ❒ Antidepressants, ❒ Antidiabetic Agent, ❒ Antiemetic Agents, ❒ Antihistamine, ❒ Antihyperlipidemics ❒, ❒ Antiinfective, ❒ Anxiolytics, ❒ Cardiac Agents, ❒ EENT-Antiallergics, ❒ EENT-Vasoconstrictors, ❒ Estrogens, ❒ H2 Antagonist, ❒ Intranasal Corticosteroids ❒, ❒ Platelet Aggregation Inhibitors, ❒ Skin & Mucous Membrane Agent, ❒ PPI, ❒ Triptans, ❒ Respiratory Agents ❒ Skeletal, ❒ Other, and List previous drug usage and area.

step 2 to entering details in eent

You may be required to note the particulars to let the software prepare the area Generic/Brand/OTC, Generic/Brand/OTC, Reason for d/c, Reason for d/c, Therapy start date, Therapy end date, Therapy start date, Therapy end date, If no previous drug usage, DISPENSING PHARMACY INFORMATION, May Be Completed by Pharmacy, Dispensing pharmacy, NPI #, Phone # with area code Fax # with, NDC #, NOTE: See Instruction sheet for, Form 369 Revised 4/9/08, and Alabama Medicaid Agency.

step 3 to completing eent

The ❒❒❒❒❒ Sustained Release Oral, Proposed duration of therapy Type, Reason for d/c Reason for d/c, Is medicine for PRN use, Severity of pain: ❒ Mild ❒, ❒❒❒❒❒ Biological Injectables ❒, Current weight, If rheumatoid arthritis, ❒ Yes ❒ No ❒ Yes ❒ No, ❒ Yes ❒ No, ❒ No, and ❒ Yes section needs to be used to put down the rights or responsibilities of both sides.

Filling in eent part 4

Look at the fields ❒❒❒❒❒ XenicalR, ❒ If initial request Weight ❒ If, BMI kg, Height kg, Current weight, inches, kg/m2, ❒❒❒❒❒ Phosphodiesterase Inhibitors, Failure or inadequate response to, ❒ Documentation of vasoreactivity, ❒ Consultation with specialist, ❒❒❒❒❒ Specialized Nutritionals, Height, inches Current weight, ❒ If < 21 years of age, Method of administration, Duration, # of refills, ❒❒❒❒❒ XolairR, Current weight, and Is treatment recommended by a and next fill them out.

step 5 to finishing eent

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