Alabama Form 369 is a 2-page Medicaid Pharmacy Prior Authorization Request Form administered by the Alabama Medicaid Agency. The form is required when a prescriber needs approval for a medication that is not automatically covered under the standard Alabama Medicaid formulary.
The form is organized into six main sections. The patient section collects name, Medicaid ID number, date of birth, phone number, and nursing home residency status. The prescriber section requires the provider name, National Provider Identifier (NPI), DEA or license number, address, and phone and fax numbers. The clinical information section asks for the drug name, strength, quantity, days supply, J code, one or more ICD diagnosis codes, and a written medical justification explaining why the specific medication is necessary. A fourth section categorizes the drug type (antipsychotic, opioid, nutritional, or other) with targeted follow-up questions for each category. The fifth section captures dispensing pharmacy details including the pharmacy name, NPI, and NDC number. The sixth section records prior drug therapy: prior medications tried, durations of use, and reasons for discontinuing previous treatments.
Incomplete submissions and missing medical justification are the most common reasons the Alabama Medicaid Agency delays or denies prior authorization requests. All prescribers must certify that the requested medication is medically necessary and cost-effective before submitting Form 369. For related forms, see the Alabama Medicaid Referral Form or the Drug Prior Authorization Form.
| 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 |
