PDF Version
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective October 1, 2016, the Alabama Medicaid Agency will:
1. Include folic acid tablets in the mandatory three-month maintenance supply program.
Prescriptions for three-month maintenance supply medications will not
count toward the monthly prescription limit. A maintenance supply
prescription will be required after 60 days stable therapy. Please see
the website for a complete listing of maintenance supply medications.
2.
Require prior authorization (PA) for payment of olopatadine nasal spray
(generic Patanase). Brand Patanase will be preferred without PA.
Use
Dispense as Written (DAW) Code of 9 for brand Patanase. DAW Code of 9
indicates the following: Substitution Allowed by Prescriber but Plan
Requests Brand. This value is used when the prescriber has indicated, in
a manner specified by prevailing law, that generic substitution is
permitted, but the Plan requests the brand product to be dispensed.
3. Remove prior authorization from lidocaine patches (generic Lidoderm). Brand Lidoderm will now require PA.
4. Remove prior authorization from tobramycin inhalation solution (generic Tobi). Brand Tobi will now require PA.
5. Update the PDL to reflect the quarterly updates. The updates are listed below:
PDL Additions
|
|
Besivance
|
EENT
Antibacterial Agents
|
|
Blephamide
|
EENT
Antibacterial Agents
|
|
Cortisporin-TC
|
EENT
Antibacterial Agents
|
|
Levemir
|
Insulins
|
|
lidocaine
patches (generic)
|
Skin and
Mucous Membrane Agents-Antipruritics
|
|
Moxeza
|
EENT
Antibacterial Agents
|
|
Patanase
|
EENT
Antiallergic Agents
|
|
Pazeo
|
EENT
Antiallergic Agents
|
|
tobramycin
inhalation solution (generic)
|
Aminoglycosides
|
|
|
Vigamox
|
EENT
Antibacterial Agents
|
|
ZepatierCC
|
HCV
Antivirals
|
|
Zylet
|
EENT
Antibacterial Agents
|
|
cc Preferred with Clinical Criteria
|
|
|
The
Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes
descriptors, and other data are copyright © 2016 American Medical Association
and © 2016 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.
PDL Deletions
|
Combivent
|
Respiratory
Beta-Adrenergics
|
Lidoderm
Patches
|
Skin and
Mucous Membrane Agents -Antipruitics
|
Mentax
|
Skin and
Mucous Membrane Agents -Antifungals
|
metformin
ER (generic of brand Fortamet ER and Glumetza ER)
|
Biguanides
|
ofloxacin
otic drops (generic)
|
EENT
Antibacterials
|
olopatadine
nasal spray (generic)
|
EENT
Antiallergic Agents
|
Pataday
|
EENT
Antiallergic Agents
|
Tobi
|
Aminoglycosides
|
cc Preferred with Clinical Criteria
The
Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes
descriptors, and other data are copyright © 2016
American Medical Association and © 2016 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.
For additional PDL and coverage information, visit our drug look-up site at https://www.medicaid.alabamaservices.org/ALPortal/NDC%20Look%20Up/tabId/39/Default.aspx.
The
PA request form and criteria booklet, as well as a link for a PA
request form that can be completed and submitted electronically online,
can be found on the Agency’s website at www.medicaid.alabama.gov and
should be utilized by the prescriber or the dispensing pharmacy when
requesting a PA. Providers requesting PAs by mail or fax should send
requests to:
Health Information Designs (HID)
Medicaid Pharmacy Administrative Services
P. O. Box 3210 Auburn, AL 36832-3210
Fax: 1-800-748-0116
Phone: 1-800-748-0130
Incomplete
PA requests or those failing to meet Medicaid criteria will be denied.
If the prescriber believes medical justification should be considered,
the prescriber must document this on the form or submit a written letter
of medical justification along with the PA form to HID. Additional
information may be requested. Staff physicians will review this
information.
Policy questions concerning this provider notice
should be directed to the Pharmacy Program at (334) 242-5050. Questions
regarding PA procedures should be directed to the HID help desk at
1-800-748-0130.