PDF Version
TO: Pharmacies, Physicians, Physician
Assistants, Nurse Practitioners, Oral
Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service
Providers and Nursing Homes
Effective July 2, 2018, the Alabama Medicaid Agency will:
- Implement a Prospective DUR Ingredient
Duplication Edit. The new edit will review claims history
for possible ingredient
duplication and deny claims when simultaneous use of medications
containing the same active ingredient and prescribed by different
prescribers are detected. The drugs to be included in the
in the ingredient duplication edit are:
* Pregabalin (ex. Lyrica)
* Gabapentin (ex. Neurontin)
The new ingredient duplication edit will not be able to be overridden with
conflict/intervention/outcome codes but will require a manual override.
Requests should be submitted to Health Information Designs using Form 409
(Override Request Form). Medical
justification is required for patients to be on 2 strengths/formulations
of the same medication at the same time by different prescribers and must
be included on the form. The form
can be found at
http://www.medicaid.alabama\.gov/documents/9.0_Resources/9.4_Forms_Library/
9.4.14_PA_Forms/9.4.1.4_PH_PA_Form_409_Override_Fillable_7-2-18.pdf.
- Include the Complement
Inhibitors used to treat Hereditary Angioedema (HAE) in the Preferred Drug
List (PDL).
- Remove prior authorization from
esomeprazole magnesium (generic Nexium). Brand
Nexium will now require PA.
- Require Prior Authorization (PA) for darifenacin ER (generic
Enablex) and glatiramer (generic Copaxone). Brand Enablex will be
added as preferred without PA. Brand Copaxone will remain
preferred.
Use Dispense as Written (DAW) Code of 9 for brand Enablex and
Copaxone. 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
|
CitraNatal
RX
|
Prenatal
Vitamins
|
Enablex
|
Genitourinary
Smooth Muscle Relaxants
|
Esomeprazole
Magnesium (generic Nexium)
|
Proton-Pump
Inhibitors
|
Moxeza
|
EENT-Antibacterials
|
SuboxoneCC
|
Opiate
Partial Agonists
|
Vyvanse
Chewable Tablets
|
ADHD
|
PDL Deletions
|
Darifenacin
ER (generic Enablex)
|
Genitourinary
Smooth Muscle Relaxants
|
Dulera
|
Respiratory
Corticosteroids
|
Extavia
|
Multiple
Sclerosis
|
Glatiramer
(generic Copaxone)
|
Multiple
Sclerosis
|
Nexium
|
Proton-Pump
Inhibitors
|
Relpax
|
Selective
Serotonin Agonists
|
Technivie
|
HCV
Antivirals
|
Viekira
Pak
|
HCV
Antivirals
|
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 © 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.