Please rate Alabama Form 369 Revised 10-01-24
The prescribing practitioner certifies that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency.
Brand name: 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 Acentra Health.
Where to send: Fax (800) 748-0116 or mail to Acentra Health, P.O. Box 3570, Auburn, AL 36831-3210.
Polytherapy: For polytherapy and/or off-label use, please provide medical justification to support the use of the drug being requested.
Pharmacy: The dispensing pharmacy information may be completed by pharmacy.
| Question | Answer |
|---|---|
| Form Name | Form 369 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 163 |
| Avg. time to fill out | 28 min |
| Edition | Revised 10/01/24 |
| Issuing agency | Alabama Medicaid Agency |
| Where to send | Fax (800) 748-0116 or mail to Acentra Health, P.O. Box 3570, Auburn, AL 36831-3210 |
| Other names | Form 369, Alabama Medicaid Form 369, Alabama Medicaid Pharmacy Prior Authorization Request Form, Alabama Medicaid PA form |
| Official source | Form 369 (Rev 10/01/24), Alabama Medicaid Agency |
Alabama Form 369 isn’t the one you’re looking for?
Please rate Alabama Form 369 Revised 10-01-24
