Alaska Medicaid prescribers use this two-page form to request prior authorization for a medication that lacks its own drug-specific form, or to exceed the maximum allowed units. It collects member, prescriber, pharmacy and drug details, then diagnoses, current medications and medical justification, including previous failed therapies with dates. Prime Therapeutics reviews pharmacy PA requests for the Alaska Department of Health.
The prescriber completes the whole form and signs the required attestation that the treatment is indicated, necessary and meets Alaska Medicaid guidelines. A requestor name and title can be added when staff prepare the request.
Download the current version from the source each time; forms change without notice.
Alaska Medicaid General Prior Authorization Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Use it for any medication requiring prior authorization that does not have a drug-specific Alaska Medicaid form, and for requests to exceed the maximum allowed units. Separate forms exist for drugs such as atypical antipsychotics, growth hormone, Synagis and hepatitis C antivirals.
Yes. Alaska Medicaid's medication prior authorization page links to electronic prior authorization (ePA) through CoverMyMeds. The fillable PDF can also be completed and faxed to Prime Therapeutics, which handles the pharmacy PA review.