Criteria Instruction Booklet - Alabama Medicaid Agency 2025

1. Click ‘Get Form’ to open the Criteria Instruction Booklet in the editor.
2. Begin with Section 1: General Information. Fill in the required details about preferred drugs and stable therapy guidelines as applicable.
3. Proceed to Section 2: Patient Information. Enter the patient's name, Medicaid number, date of birth, phone number, and nursing home residency status.
4. In Section 3: Prescriber Information, input the prescriber's name, license number, contact details, and ensure they sign and date this section.
5. Complete Section 4: Dispensing Pharmacy Information by entering the pharmacy's name, provider number, and contact information.
6. For Section 5: Drug/Clinical Information, provide details on the drug requested including strength, quantity per month, diagnosis codes, and any necessary medical justification.
7. Continue through Sections 6 to 8 by following specific instructions for drug-specific information and FAQs as needed.

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