Alabama Form 390 – Fill Out and Use This PDF

Alabama Form 390 PDF Details

Alabama Form 390 is a prior authorization document used by Medicaid enrollees who require medications or treatments not automatically covered under the Alabama Medicaid program. Prescribers and pharmacies submit it to demonstrate that the requested treatment meets Alabama Medicaid Agency guidelines before the medication is dispensed.

The form is sent to Health Information Designs via fax or mail. Key information required on the form includes:

• Patient name, Medicaid ID number, and date of birth
• Prescriber name, NPI number, and state license number
• Dispensing pharmacy name, phone, fax, and NPI
• Drug name, NDC code, strength, quantity, and number of days or weeks requested
• ICD-9 or ICD-10 diagnosis codes that justify the medication
• Medical justification for the treatment, referencing clinical guidelines or prior treatment failures
• EPSDT notation for eligible Medicaid recipients under age 21

For compounding prescriptions, the form requires the compounding ingredients, quantities, and time units requested. The prescribing practitioner must certify that the treatment is medically necessary and follows all Alabama Medicaid guidelines.

Related forms that may be required alongside Form 390 include the Alabama Medicaid Referral form and the Pharmacy Prior Authorization form. Healthcare providers who work with multiple payer types may also need to complete an Aetna Pharmacy Prior Authorization form for patients with private insurance.