PDF Version
TO: Pharmacies, Physicians,
Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists,
Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective January 1, 2018,
the Alabama Medicaid Agency will:
1.
Update the PDL to reflect
the quarterly updates. The updates are listed below:
PDL Additions
|
EpclusaCC
|
HCV Antiviral
|
MavyretCC
|
HCV Antiviral
|
ZepatierCC
|
HCV Antiviral
|
PDL Deletions
|
Viekira
XR
|
HCV Antiviral
|
CC
Preferred
with Clinical Criteria
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.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2017 American Medical
Associationand © 2017 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.