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TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective April 1, 2018 the Alabama Medicaid Agency will:
1. Update the PDL to reflect the quarterly updates. The updates are listed below:
PDL Additions |
Alvesco |
Orally Inhaled Corticosteroids |
Asmanex HFA |
Orally Inhaled Corticosteroids |
Citranatal Bloom |
Prenatal Vitamins |
Ezetimibe (generic Zetia) |
Cholesterol Absorption Inhibitors |
Flovent Diskus |
Orally Inhaled Corticosteroids |
Flovent HFA |
Orally Inhaled Corticosteroids |
Nasonex |
Intranasal Corticosteroids |
Pulmicort Flexhaler |
Orally Inhaled Corticosteroids |
Seebri |
Inhaled Antimuscarinic |
Symbicort |
Orally Inhaled Corticosteroids |
Tudorza |
Inhaled Antimuscarinic |
Xopenex HFA |
Respiratory Beta Agonists |
Zetonna |
Intranasal Corticosteroids |
Zyflo CR |
Leukotriene Modifiers |
PDL Deletions |
Levalbuterol HFA (generic Xopenex HFA) |
Respiratory Beta Agonists |
Qnasl |
Intranasal Corticosteroids |
Qnasl Children |
Intranasal Corticosteroids |
Qvar |
Orally Inhaled Corticosteroids |
Zetia |
Cholesterol Absorption Inhibitors |
Zileuton ER (generic Zyflo CR) |
Leukotriene Modifiers |
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 © 2018 American Medical Association
and © 2018 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.