Alabama Form 369 – Fill Out and Use This PDF

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)

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

Diagnosis or ICD-9/ICD-10 Code

r Initial Request

r Renewal

r

Maintenance Therapy

r Acute Therapy

Medical justification

r Additional medical justification attached.

Medications received through coupons and samples are not acceptable as justification.

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 #

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

r

If initial request

Weight

kg.

Height

inches

BMI

kg/m2

r

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.

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