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.
No material clinical/coverage changes identified.
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).
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