Alabama Medicaid prescribers use Form 369 to request prior authorization for non-preferred drugs and other drugs that require PA when no drug-specific form applies. Page 1 collects patient, prescriber and clinical details, previous drugs with start and end dates, and medical justification. Pages 2 and 3 add drug-specific questions. Acentra Health reviews requests for the Alabama Medicaid Agency.
The prescribing practitioner completes the patient, prescriber and clinical sections and signs a certification that the treatment is indicated, necessary and within Medicaid guidelines and that they will supervise it. The dispensing pharmacy section may be completed by the pharmacy.
Download the current version from the source each time; forms change without notice.
Alabama Medicaid Pharmacy Prior Authorization Request Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Use it for a non-preferred drug or a drug that requires prior authorization when no drug-specific form applies. DMARDs and biologics, Synagis, hepatitis C antivirals, growth failure agents, smoking cessation agents and opioid dependence agents each have separate PA forms and instructions.
For drug classes in the electronic PA program, the system checks the patient's medical and pharmacy claims history. If criteria are met, the claim is approved automatically. If not, the pharmacy is told to submit a manual paper or online request; that rejection is not a PA denial.
Documentation supporting the prescriber's choice of treatment, such as records from the patient chart or peer-reviewed literature, listed in the justification field with extra pages attached if needed. Previous drugs should show generic, brand or OTC status, reason for discontinuation and therapy start and end dates.