CurrentAlaska MedicaidPolicy N/A

Physician-Administered Drug General Prior Authorization Form

A fillable prior authorization request form used by Alaska Medicaid for physician-administered drugs, including requests to exceed maximum allowed units. It collects requester, member, prescriber, billing provider, drug, and clinical justification information and provides submission instructions.

Policy Summary

PayerAlaska Medicaid

PolicyPhysician-Administered Drug General Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and submit the Physician-Administered Drug General Prior Authorization Form to Alaska Medicaid to request approval for physician-administered drugs or to request exceeding maximum allowed units.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified.

1Form pages represented

0Specific drug policies included

Policy overview

This is the standardized Physician-Administered Drug General Prior Authorization Form for Alaska Medicaid. The form is used to request prior authorization for physician-administered drugs and may also be used to request authorization to exceed the maximum allowed units.

The form collects administrative and clinical data necessary for review, including requester information (name, title), member information (name, Member ID, date of birth, sex, phone), prescriber information (name, NPI, specialty, phone, fax), billing provider information (name, NPI, phone, fax/DSM), and detailed drug information (drug name, NDC, drug strength, dosage form, HCPCS code, dosage schedule, total HCPCS unit quantity, day supply, and whether the drug is physician-administered).

Clinical justification fields include primary and other diagnoses, current medications, and medical justification including previous failed therapies with dates; the form also indicates when chart notes are required as attachments. Submission instructions and attestation requirements (prescriber signature and date) are provided, and the form notes that authorization does not ensure eligibility or guarantee payment and that incomplete requests will be denied.

What providers must do

Prior Authorization

Submit prior authorization request using form

Complete and submit the Physician-Administered Drug General Prior Authorization Form to Alaska Medicaid to request approval for physician‑administered drugs or to request exceeding maximum allowed units.

Documentation Required

Attach chart notes and clinical justification

Include primary and other diagnoses, current medications, medical justification including previous failed therapies with dates, and attach chart notes when indicated. Incomplete requests will be denied until all required information is received.

Documentation Required

Prescriber signature required

Prescriber signature and date are required as an attestation that the treatment is indicated and meets Alaska Medicaid guidelines.

Billing Rule

Verify Medicaid eligibility before submission

Verify Medicaid eligibility prior to completing and submitting the form. Authorization does not guarantee eligibility or payment.

Billing Rule

Submission options

Fax the completed form to (888) 772-3632 or DSM the form to ServiceAuthorization@hms.fa.direct.

Form usage and purpose

This form may be used to request authorization to exceed the maximum allowed units and serves as the mechanism to collect the clinical and administrative data required for review.

Required clinical information collected includes primary and other diagnoses, current medications, medical justification with previous failed therapies and dates, and any chart notes indicated as attachments; prescriber attestation with signature and date is required to certify that treatment is indicated and meets Alaska Medicaid guidelines.