The Alabama 369 form is a request form used for prior authorization of medications under the Alabama Medicaid program. This form captures essential patient and prescriber information, clinical details, and specific medication requests. Proper completion of the form is crucial for ensuring that patients receive the necessary medications in a timely manner.
The Alabama 369 form serves as a vital tool in the process of obtaining prior authorization for medications under the Alabama Medicaid program. This form is designed to streamline communication between healthcare providers and the Medicaid Agency, ensuring that patients receive the necessary treatments in a timely manner. It collects essential information about the patient, including their Medicaid number, date of birth, and contact details, as well as details about the prescribing practitioner. The form requires specific clinical information, such as the drug requested, dosage, and the medical justification for its use. Additionally, it allows for the documentation of previous therapies and their outcomes, which is crucial for assessing the need for the requested medication. The form also addresses various medication categories, from antidepressants to antipsychotic agents, and includes sections for detailing any history of substance abuse or alternative therapies attempted. By facilitating a clear and organized submission process, the Alabama 369 form plays a significant role in promoting patient care and ensuring compliance with Medicaid guidelines.
Page 1
Alabama Medicaid Pharmacy
Prior Authorization Request Form
rPage 1 of 1 r Page 1 of 2
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)
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
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
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.
*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 HID in addition to the PA Request Form.
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
If no previous drug usage, additional medical justification must be provided.
DISPENSING PHARMACY INFORMATION
May Be Completed by Pharmacy
Dispensing pharmacy
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
rSustained Release Oral Opioid Agonist
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
If yes, is treatment plan attached?
r Yes r No
Indicate prior and/or current analgesic therapy and alternative management choices
Drug/therapy
The request is for:
r Monotherapy or r Polytherapy
For children < 6 years of age, have monitoring protocols (see Attachment C on the Alabama Medicaid website) been followed? r Yes r 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 the support the diagnosis, etc.
rXenicalR
If initial request
Weight
kg.
Height
inches
BMI
kg/m2
If renewal request
Previous weight
Current weight
Documentation MD supervised exercise/diet regimen > 6 mo.? r Yes
Planned adjunctive therapy? r Yes
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
rIf < 21 years of age, record supports that > 50% of need is met by specialized nutrition
rIf > 21 years of age, record supports 100% of need is met by specialized nutrition
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?
Yes
No
Is the request for chronic idiopathic urticaria?
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)?
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?
Are the patient’s baseline IgE levels between 30 IU/mL and 700 IU/mL?
Level:_________________
Date:__________________
Revised 7-1-15
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Alabama Environment - Patients dismissed from a practice may still require ongoing care and referrals.
The Alabama 369 form, a key document for requesting prior authorization for medications under Medicaid, shares similarities with the CMS 1500 form. The CMS 1500 form is used by healthcare providers to bill Medicare and Medicaid for medical services. Both forms require detailed patient information, including demographics and diagnosis codes. However, while the Alabama 369 focuses specifically on medication requests and justification for their use, the CMS 1500 encompasses a broader range of services, including consultations, procedures, and diagnostic tests. This makes the CMS 1500 a foundational document in medical billing, while the Alabama 369 is more specialized in its scope.
Another document that resembles the Alabama 369 is the Prior Authorization Request Form used by private insurance companies. Like the Alabama 369, this form requires information about the patient, the prescribed medication, and the clinical justification for its use. Both documents aim to ensure that prescribed treatments meet specific medical necessity criteria. However, the private insurance prior authorization forms may vary widely in their requirements and processes, reflecting the diverse policies of different insurers, whereas the Alabama 369 adheres to the specific guidelines set by the Alabama Medicaid Agency.
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The Drug Utilization Review (DUR) form is also similar to the Alabama 369 form. DUR forms are used to evaluate the appropriateness of prescribed medications based on patient history and medication interactions. Both forms require detailed clinical information and justification for medication use. However, while the Alabama 369 is focused on obtaining prior authorization for a specific medication, the DUR form is often used retrospectively to assess the appropriateness of medications already prescribed. This highlights a difference in timing and purpose, with the DUR serving as a quality control measure after prescriptions have been made.
Additionally, the Patient Assistance Program (PAP) application shares characteristics with the Alabama 369 form. PAP applications are designed to help patients access medications they cannot afford. Both forms require patient information, medication details, and sometimes clinical justification. However, the primary difference lies in their intent; the Alabama 369 is about gaining approval for medication coverage under Medicaid, while PAP applications are focused on securing free or discounted medications from pharmaceutical companies. This distinction emphasizes the different pathways patients can take to access necessary treatments.
Lastly, the Formulary Exception Request form is akin to the Alabama 369. This document is utilized when a prescribed medication is not included in a health plan’s formulary, which lists covered drugs. Like the Alabama 369, it requires clinical justification and patient information. However, the formulary exception process often involves a review of alternative medications that are covered, while the Alabama 369 is specifically tailored to seek approval for a particular medication that may require additional scrutiny. Both forms aim to ensure that patients receive appropriate medications, albeit through different mechanisms within the healthcare system.
Here are some important points to keep in mind when filling out and using the Alabama 369 form:
Completing the Alabama 369 form accurately can significantly improve the chances of approval for medication requests. Always double-check for any missing information before submission.
The Alabama 369 form is a Medicaid Pharmacy Prior Authorization Request Form. It is used by healthcare providers to request approval for specific medications that may not be covered under Alabama Medicaid without prior authorization. This form ensures that the requested treatment meets the necessary guidelines set by the Alabama Medicaid Agency.
The form must be completed by the prescribing healthcare provider. This includes doctors, nurse practitioners, or physician assistants who are authorized to prescribe medications. The provider must ensure that the requested treatment is appropriate for the patient’s condition and meets Medicaid guidelines.
Essential details include:
Additionally, the form requires documentation of previous treatments and any supporting medical justification for the requested medication.
The completed form can be submitted via fax or mail. For fax submissions, use the number (800) 748-0116. If mailing, send it to the address provided on the form: P.O. Box 3210, Auburn, AL 36823-3210. Make sure to keep a copy for your records.
Once the Alabama 369 form is submitted, it will be reviewed by the Medicaid agency. They will determine whether the requested medication meets the necessary criteria for approval. The prescriber will receive notification regarding the approval or denial of the request.
Yes, the Alabama 369 form is specifically used for medications that may require prior authorization. This includes a variety of drug categories such as antidepressants, antipsychotics, and narcotics, among others. If a drug has a generic equivalent available, additional forms may be required.
If the request for prior authorization is denied, the prescriber has the right to appeal the decision. The appeal process typically involves submitting additional documentation or justification to support the need for the medication. The prescriber will be informed of the specific steps to take in the appeal process.
If assistance is needed while completing the Alabama 369 form, healthcare providers can contact the Alabama Medicaid Agency directly at (800) 748-0130. They can provide guidance on how to fill out the form correctly and answer any questions regarding the prior authorization process.
While there is no specific deadline mentioned for the submission of the Alabama 369 form, it is advisable to submit the request as soon as possible to avoid delays in treatment. It is essential to ensure that the patient receives the necessary medication without unnecessary interruptions.