December 1, 2016

State of Alabama
Press Release: Medicaid

PDL Quarterly Updates

PDF Version

TO:  Pharmacies, Physicians, Physician Assistants, Nurse Practitioners,

        Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental

        Health Service Providers and Nursing Homes

Effective January 3, 2017, the Alabama Medicaid Agency will:

1. Require prior authorization (PA) for payment of mometasone

    nasal spray (generic Nasonex).

2. Require prior authorization for generic tobramycin inhalation

    solution (generic Tobi and Kitabis). Brand Kitabis will remain

    preferred without PA.

    Use Dispense as Written (DAW) Code of 9 for brand Kitabis. 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.    Update the PDL to reflect the quarterly updates. The updates are listed


PDL Additions


Intranasal Corticosteroids

Viekira XRCC

HCV Antivirals

PDL Deletions

Anoro Ellipta

Respiratory Beta-adrenergic Agonists

mometasone nasal spray (generic Nasonex)

Intranasal Corticosteroids


Intranasal Corticosteroids

Provida DHA

Prenatal Vitamins

tobramycin inhalation solution (generic Tobi and Kitabis)


                                          cc Preferred with Clinical Criteria

For additional PDL and coverage information, visit our drug look-up site at


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 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.

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.

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