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Get AL Form 369 2019-2024

Alabama Medicaid Pharmacy Prior Authorization Request Form Page 1 FAX 800 748-0116 Phone 800 748-0130 r Page 1 of 1 Fax or Mail to Health Information Designs P. O. Box 3210 Auburn AL 36823-3210 PATIENT INFORMATION Patient name Patient DOB Patient Medicaid Patient phone with area code Nursing home resident r Yes PRESCRIBER INFORMATION Prescriber name NPI Phone with area code Address Optional License Fax with area code 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 CLINICAL INFORMATION Drug requested J Code If applicable Qty. Initial Request Strength Days supply Diagnosis or ICD-9 Code r PA Refills 0 1 2 3 4 5 Other Renewal 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 Antiemetic Agents r Antihistamine r Antihyperlipidemics r Antihypertensives r Antiinfective Anxiolytics Sedatives and Hypnotics r Cardiac Agents r EENT-Antiallergics r EENT-Vasoconstrictors r Estrogens r H2 Antagonist r Intranasal Corticosteroids r NSAID r Oral Anticoagulants r Platelet Aggregation Inhibitors r Narcotic Analgesics r PPI r Other r Respiratory Agents r Antidiabetic Agent r Skeletal Muscle Relaxants r Skin Mucous Membrane Agent r Triptans List previous drug usage and length of treatment as defined in instructions for drug class requested* r Antipsychotic Agents 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 Form 369 Revised 7/1/15 www. medicaid*alabama*gov Page 2 r Sustained 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 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 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* that the support the diagnosis etc* r XenicalR r If initial request r If renewal request Previous weight Weight kg.

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