Alabama Form 409 PDF Details

Navigating the healthcare system requires an understanding of numerous forms and procedures, especially when it comes to ensuring that patients receive the medication they need despite bureaucratic hurdles. The Alabama 409 form serves as an essential tool in this process for individuals covered by Medicaid in the state of Alabama. This document enables healthcare providers to request overrides for pharmacy benefits limits on behalf of their patients. Its sections collect comprehensive information, including patient identification, prescriber details, and the specific pharmaceutical needs – ranging from requests for early refills to exceptions for therapeutic duplications and brand limit switches. Furthermore, this form embodies the commitment of healthcare providers to their patients' wellbeing, as it demands a certification of the necessity and appropriateness of the requested medication, supplemented by a guarantee of ongoing supervision by the prescribing practitioner. Designed to be user-friendly, it can be filled out electronically via Adobe Acrobat Reader, then printed and dispatched to Health Information Designs via fax or mail, streamlining the request process to facilitate timely access to crucial medications.

QuestionAnswer
Form NameAlabama Form 409
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2020 alabama withholding form, state withholding form alabama, medicaid pharmacy override, request alabama pharmacy

Form Preview Example

This form can be filled out while viewing in Adobe Acrobat Reader. Then print it and fax or mail to HID

Alabama Medicaid Pharmacy

Override Request Form

FAX: (800) 748-0116

 

 

 

Fax or Mail to

 

 

 

P.O. Box 3210

 

Phone: (800) 748-0130

 

 

HEALTH INFORMATION DESIGNS

 

 

 

Auburn, AL 36832-3210

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient name

 

 

 

 

 

 

 

 

Patient Medicaid #

 

 

Patient DOB

Patient phone # with area code

 

 

Nursing home resident ❒ Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESCRIBER INFORMATION

 

 

 

 

 

 

 

 

 

Prescriber name

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone # with area code

 

 

 

 

 

 

 

Fax # with area code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street or PO Box /City/State/Zip

I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I will be supervising the patient’s treatment. Supporting documentation is available in the patient record.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescribing Practitioner Signature

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISPENSING PHARMACY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dispensing pharmacy

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

NDC #

 

 

 

 

 

 

 

 

J Code

 

 

 

 

 

 

Qty. requested per month

 

 

Phone # with area code

 

 

 

 

 

 

Fax # with area code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❒

Early Refill

❒ Maximum Unit/Maximum Cost

❒

Therapeutic Duplication

❒ Brand Limit Switch Over

Requested drug name

 

 

 

 

 

Strength

 

 

Date of request

 

 

 

For Early Refill

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❒

 

Medication lost

 

 

❒ Physician changed the dosage

 

 

 

 

❒

 

Medication destroyed

 

❒ Medication stolen

 

 

 

 

❒Patient going out of town for period greater than the day’s supply remaining of the previous refill.

Documentation

❒ Supporting Documentation Attached

For Maximum Unit or Maximum Cost

Diagnosis

Medical Justification

For Therapeutic Duplication or ◆Brand Limit Switch Over

 

Diagnosis

 

Reason for Request

❒ Strength/Dosage change*

❒ Switch over

 

 

❒

Titration and Concomitant Therapy**

❒ Drug name

 

NDC

 

 

 

Qty.

 

 

Stop date

 

 

 

 

 

 

 

 

 

 

 

 

if applicable

❒ Drug name

 

NDC

 

 

 

Qty.

 

 

Stop date

 

 

 

 

 

 

 

 

 

 

 

 

if applicable

Reason for change

 

 

 

 

 

 

 

 

 

 

 

* Stop date is required for strength/dosage change or switch over.

 

 

 

 

❒ Medical justification attached

**Attach medical justification if both drugs are to be continued (titration/concomitant therapy). ◆ For specific documentation requirement, see Override instructions on the Medicaid web site.

FOR HID USE ONLY

❒ Approve request

❒ Deny request

❒ Modify request

❒ Medicaid eligibility verified

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewer’s Signature

 

 

 

Response Date/Hour

Form 409

 

 

 

Alabama Medicaid Agency

Revised 2/23/08

 

 

 

www.medicaid.alabama.gov

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2. The next stage is usually to submit these particular fields: Requested drug name For Early, Strength, Date of request, Medication lost Medication, Physician changed the dosage , Documentation, Supporting Documentation Attached, For Maximum Unit or Maximum Cost, Diagnosis, Medical Justification, For Therapeutic Duplication or, Diagnosis, Switch over, Titration and Concomitant Therapy, and Drug name.

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