PDF VERSION
TO: Pharmacies,
Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons,
Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and
Nursing Homes
Effective October 2, 2017,
the Alabama Medicaid Agency will:
- Include pancreatic enzymes and vitamin B-12
injection 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.
- Require Prior Authorization (PA) for ezetimibe
(generic Zetia), methylphenidate ER (generic Concerta), and moxifloxacin
(generic Vigamox). Brand Concerta and Zetia
will be added as preferred without PA.
Brand Vigamox will remain preferred.
Use Dispense as Written
(DAW) Code of 9 for brand Concerta, Vigamox and Zetia. 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.
- Update the PDL to reflect the quarterly
updates. The updates are listed below:
PDL Additions
|
Adzenys XR
|
ADHD Agents
|
Brilinta
|
Platelet Aggregation Inhibitors
|
Concerta
|
ADHD Agents
|
Eliquis
|
Oral Anticoagulants
|
Entresto
|
RAAS Inhibitors
|
Ofloxacin Otic Drops
|
EENT Antibacterials
|
Pradaxa
|
Oral Anticoagulants
|
Xarelto
|
Oral Anticoagulants
|
Zetia
|
Cholesterol Absorption
Inhibitors
|
PDL Deletions
|
Bactroban Nasal
|
EENT Antibacterials
|
Cortisporin-TC
|
EENT Antibacterials
|
Ezetimibe (generic Zetia)
|
Cholesterol Absorption
Inhibitors
|
Methylphenidate
ER (generic Concerta)
|
ADHD Agents
|
Moxeza
|
EENT Antibacterials
|
Moxifloxacin (generic
Vigamox)
|
EENT Antibacterials
|
Zepatier
|
Hepatitis C Antivirals
|
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.