Alaska Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

An Alaska Medicaid prior authorization form is filled out by a medical professional in order to request coverage through state Medicaid for a non-preferred drug prescription. Once completed, this form can be submitted to the fax number provided below. For more information, call the phone number found immediately below the fax number.

Fax – 1 (888) 603-7696

Phone – 1 (800) 331-4475

Preferred Drug List – Acceptable drugs by the State

How to Write

Step 1 – In the “Requestor” field, provide the requestor’s full name and title.

Step 2 – Next, provide the full name, date of birth, ID number, and gender of the patient in the section marked “Recipient”.

Step 3 – In the “Prescriber” field, you will need to provide the full name, NPI number, phone and fax number, and the specialty of the prescriber.

Step 4 – In the “Pharmacy” section, supply the full name, NPI number, phone and fax number of the supplying pharmacy.

Step 5 – In the “Request” section of the form, you will provide the name, strength, dosage form, primary diagnosis, dosage schedule, other diagnoses, quantity, and day supply of the drug for which coverage is being requested.

Step 6 – Finally, in “Rationale for Prior Authorization”, enter the prior authorization start date, list any current medications that the patient is taking, and provide your medical justification for making this request. You must list any other therapies that have been tried and failed in the treatment of the relevant diagnosis. When you have finished filling out the form, supply your written signature and the date.