Alabama Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

An Alabama Medicaid prior authorization is an appeal to the State that a specific non-preferred drug should be prescribed by a physician and covered under the State’s Medicaid coverage. It may either be filed in its paper form or submitted online. A fillable PDF version of this form can be downloaded on this page.

E-Mail – al_pa@hidinc.com

Fax – 1 (800) 748-0116

Phone – 1 (800) 748-0130

Preferred Drug List – View comparable drugs that are State-approved.

Submit Online – File this form online.

How to Write (Paper Form)

Step 1 – In “Patient Information,” provide the patient’s full name, their Medicaid number, their date of birth, their phone number, and indicate if they are a nursing home resident.

Step 2 – In “Prescriber Information,” provide your complete name, your NPI number, your license number, your work phone and fax number, and your work address. You will then need to provide your written signature and the date.

Step 3 – In “Clinical Information,” enter the name, strength, J Code, quantity, days supply, and the number of PA refills for the drug that you are requesting coverage for. Next, provide the related diagnosis or ICD-10 Code and indicate whether this is an initial request, renewal, maintenance therapy, or acute therapy. You will be required to either write your medical justification for this request where indicated or attach your written justification and relevant documentation to this form.

Step 4 – In “Drug Specific Information,” check the box(es) that indicate(s) what sort of drug you are requesting. Next, if the patient has been prescribed other drugs for this diagnosis, enter the drug name, reason for discontinuation, therapy start date, and therapy end date where indicated.

Step 5 – In “Dispensing Pharmacy Information,” you will need to enter the dispensing pharmacy name, their NPI number, their phone and fax number, and their NDC number.

Step 6 – On the second page of the form, if this is a prescription for either a Sustained Release Oral Opioid Agonist, Antipsychotic Agents, Xenical, Phosphodiesterase Inhibitors, Specialized Nutritionals, or Xolair, check the appropriate box and provide the requisite information.