Alabama Medicaid Prior (Rx) Authorization Form - eForms 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the 'Patient Information' section. Enter the patient's name, Medicaid number, date of birth, and phone number. Indicate if the patient is a nursing home resident.
  3. Next, complete the 'Prescriber Information' section. Provide the prescriber's name, NPI number, contact details, and optional address. Ensure to sign and date this section to certify treatment necessity.
  4. In the 'Clinical Information' section, specify the drug requested along with its strength and quantity. Include diagnosis codes and indicate whether this is an initial request or a renewal.
  5. Fill out any relevant 'Drug Specific Information' based on the type of medication being requested. Provide details about previous treatments and justifications as required.
  6. Finally, complete the 'Dispensing Pharmacy Information' if applicable. Include pharmacy contact details and NPI number before submitting your form.

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Prior Authorization (approval in advance) is required for many procedures, services or supplies, including transportation. Click here for information on obtaining an Emergency PA for medications. Below are the forms used for Prior Authorization. Prior Review and Authorization Request Note: a completed form is required.
(800) 456-1242 (Nationwide Toll Free) Local: (334) 215-0111.
Apply online Call (800) 362-1504 (Toll-free) to find a location near you.

People also ask

Brand preferred drugs, generics (some exceptions apply) and over-the-counter (OTC) drugs covered by Medicaid are available without prior approval. If a non-preferred drug is ordered, the practitioner will need to obtain prior authorization (PA).
How many prescriptions can I get each month? Adult Medicaid recipients may get up to five total drugs (including up to four brand name drugs) per month. There are no limits on drugs for children.
Alabama Medicaid does not utilize a Pharmacy Benefits Management vendor. However, Alabama does utilize a clinical contractor to compile the clinical review packet for each PT meeting. All financial and supplemental rebate matters are coordinated by Alabama Medicaid staff.
Provider Enrollment Contact Information: (888) 223-3630 (Nationwide Toll-Free) Hours (All times Central) - Monday - Friday 8 a.m. to 5 p.m.
Claims Submission Methods Claims filed on paper must be submitted on a CMS-1500 claim form. Instructions for paper claim submission can be found in Chapter 5 of the provider billing manual.

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