Form 369: Alabama Medicaid Pharmacy Prior Authorization Request Form

Under PATIENT INFORMATION, fill in Patient name, Patient Medicaid #, Patient DOB and Patient phone # with area code; Nursing home resident has a Yes box.

Under PRESCRIBER INFORMATION, fill in Prescriber name, NPI #, License #, Phone # with area code and Fax # with area code; Address (Optional): Street or PO Box /City/State/Zip.

The Prescribing Practitioner certifies that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency, will be supervising the patient's treatment, and has supporting documentation available in the patient record.

Sign on the Prescribing Practitioner Signature line and enter the Date.

Under CLINICAL INFORMATION, enter Drug requested* and Strength, then J Code, Qty., Days' supply, PA and Refills (0, 1, 2, 3, 4, 5 or Other), then the two Diagnosis or ICD-10 Code boxes.

Mark Initial Request, Renewal, Maintenance Therapy or Acute Therapy.

Enter the Medical justification. Mark Additional medical justification attached if additional medical justification is 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 Acentra Health in addition to the PA Request Form.

Under DRUG SPECIFIC INFORMATION, mark the drug class requested: ADD/ADHD Agents, Alzheimer's Agent, Androgens, Antidepressants, Antidiabetic Agent, Antiemetic Agents, Antigout, Antihistamine, Antihyperlipidemics, Antihypertensives, Antipsychotic Agents, Antiinfective, Anxiolytics, Sedatives & Hypnotics, Cardiac Agents, CGRP/Migraine, EENT-Antiallergics, EENT-Vasoconstrictors, EENT-Antibacterials, Estrogens, Genitourinary Agents, H2 Antagonist, Hereditary Angioedema Agents, Intranasal Corticosteroids, Multiple Sclerosis, Narcotic Analgesics, NSAID, Oral Anticoagulants, Platelet Aggregation Inhibitors, PPI, Prenatal Vitamins, Respiratory Agents, Skeletal Muscle Relaxants, Skin & Mucous Membrane Agent, Triptans, Wakefulness Promoting Agents or Other. Then List previous drug usage and length of treatment as defined in instructions for drug class requested.

Enter Generic/Brand/OTC, Reason for d/c, Therapy start date and Therapy end date.

Under DISPENSING PHARMACY INFORMATION, which May Be Completed by Pharmacy, fill in Dispensing pharmacy, NPI #, Phone # with area code, Fax # with area code and NDC #.

For Sustained Release Oral Opioid Agonist, enter Proposed duration of therapy and mark Yes or No for Is medicine for PRN use?

Mark Type of pain as Acute or Chronic and Severity of pain as Mild, Moderate or Severe.

Mark Yes or No for Is there a history of substance abuse or addiction? and for If yes, is treatment plan attached?

Indicate prior and/or current analgesic therapy and alternative management choices, with Drug/therapy and Reason for d/c.

For Antipsychotic Agents, mark The request is for Monotherapy or Polytherapy. For children < 6 years of age, have monitoring protocols (see Attachment C on the Alabama Medicaid website) been followed? Yes 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 support the diagnosis, etc.

Under Calcitonin Gene-Related Peptide (CGRP)/Migraine Agents, Indicate the number of migraines per month.

Under Phosphodiesterase Inhibitors, the page prints Failure or inadequate response to the following alternate therapies as lines 1. to 6., then Contraindication of alternate therapies, and the boxes Documentation of vasoreactivity test attached and Consultation with specialist attached.

For Specialized Nutritionals, enter Height in inches and Current weight in kg.

Mark If < 21 years of age, record supports that > 50% of need is met by specialized nutrition, or If > 21 years of age, record supports 100% of need is met by specialized nutrition.

Enter Method of administration, Duration and # of refills.

For Xolair, enter Current Weight in kg (patient's weight must be between 20-150kg), and mark Yes or No for Is the patient 6 years or older? Is the request for chronic idiopathic urticaria?

Mark Yes or No for 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 it on page 2)?

Then mark Yes or No for Has the patient had a positive skin or blood test reaction to a perennial aeroallergen? 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?

Mark Yes or No for Are the patient's baseline IgE levels between 30 IU/mL and 700 IU/mL (between 30 IU/ml and 1,300 IU/ml for patients 6 to < 12 years of age)? Enter the Level and Date.

For Hereditary Angioedema Agents, mark Acute Treatment or Prophylaxis, and mark Yes or No for Has the diagnosis been confirmed by an ENT, allergist or immunologist?

Enter the Name of Specialist, the Failure or inadequate response to the following alternate therapies as lines 1. to 6., and the Contraindication of alternate therapies.

For prophylaxis, include documentation of frequency and severity of past events.

For XenicalR, mark If initial request and enter Weight (kg.), Height (inches) and BMI (kg/m2), or mark If renewal request and enter Previous weight (kg.) and Current weight (kg.).

Mark Yes or No for Documentation MD supervised exercise/diet regimen > 6 mo.? and for Planned adjunctive therapy?

Form 369 is the Alabama Medicaid Pharmacy Prior Authorization Request Form of the Alabama Medicaid Agency. See instruction sheet for specific PA requirements on the Medicaid website at www.medicaid.alabama.gov.