March 7, 2017

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 April 1, 2017, the Alabama Medicaid Agency will:

  1.  Require patient consent form for Hepatitis C medications. Prior authorization requests for Hepatitis C medications must be accompanied by the Alabama Medicaid Pharmacy Hepatitis C Agents Patient Consent Form. The form must be signed and dated by the patient and prescriber. The form can be found on the Agency website at

 2.  Include benztropine 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.

 3.  Remove prior authorization from atovaquone (generic Mepron). Brand Mepron will now require PA.

 4.  Update the PDL to reflect the quarterly updates. The updates are listed below:


 PDL Additions



PDL Deletions


Inhaled Corticosteroids


Antiprotozoals, Miscellaneous



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 © 2017 American Medical Association and © 2017 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.

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