Alaska Medicaid General Prior Authorization Form
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Template and instructions for submitting general prior authorization requests to Alaska Medicaid (Magellan Medicaid Administration) for drugs and related services; affects prescribers, pharmacies, and requestors submitting PA requests for Alaska Medicaid members.
No material clinical or coverage changes in this revision.
Required Form Information for Coverage Decisions
Required form fields
Information collected to support coverage decisions:
ALL of the following
Patient / Member information
- Member name
- Member ID
- Date of birth (DOB)
- Sex
- Phone
Clinical information
- Primary Diagnosis
Other clinical details (one or more)
- Other Diagnoses
- Current Medications
- Medical Justification (including previous failed therapies with dates)
- Attachments (optional)
- Attestation signed by prescriber certifying medical necessity and guideline compliance
Drug / request details
- Drug name
- NDC
- Strength
- Dosage form
- Dosage schedule
- Day supply
- Quantity
- Is this a physician‑administered drug? (yes/no)
Prescriber and pharmacy identifiers
- Prescriber name
- Prescriber NPI
- Prescriber specialty
- Prescriber phone
- Prescriber fax
- Pharmacy name
- Pharmacy NPI
- Pharmacy phone
- Pharmacy fax
Identifiers and Quantity/Day Supply
| NDC | Field for National Drug Code of requested drug |
| Prescriber NPI | Prescriber National Provider Identifier field |
| Pharmacy NPI | Pharmacy National Provider Identifier field |
| Member ID | Member identification number |
| Prescriber Fax | Prescriber fax number |
| Pharmacy Fax | Pharmacy fax number |
| Member DOB | Member date of birth |
| Member Sex | Member sex |
Submission, Verification, and Attestation Requirements
Submission and verification of PA requests
Complete the general prior authorization form and fax it to (888) 603-7696 or contact the Magellan PA Unit by phone. Verify Medicaid eligibility before submitting; incomplete requests will be denied until all required information is received.
- Form available on Alaska Medicaid's Medication Prior Authorization website
- This form may be used to request exceeding maximum allowed units
Clinical attestation and prescriber signature required
An attestation and prescriber signature are required certifying the treatment is indicated, necessary, and meets Alaska Medicaid guidelines; include medical justification and prior therapy failures with dates.
- Attestation text must be signed and dated by the prescriber
- Include medical justification and previous failed therapies with dates; attachments may be included
Key Terms
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