PDF Version
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners
Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service
Providers and Nursing Homes
RE: Preferred Drug List (PDL) Quarterly Update
Effective April 1, 2019 the Alabama Medicaid Agency will:
1. Require Prior Authorization (PA) for generic tobramycin/dexamethasone
ophthalmic drops, generic albuterol HFA, and generic fluticasone/salmeterol
inhalation device. Brand Tobradex and Advair
Diskus will be added as preferred. Brand
Proair HFA and Proventil HFA will remain preferred.
Use Dispense as Written (DAW) Code of 9 for
brand Tobradex, Proair HFA, Proventil HFA, and Advair Diskus. 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.
2. Remove prior authorization from budesonide respules (generic Pulmicort). Brand Pulmicort Respules will now require PA.
3. Include the Growth Hormone Agents in the Preferred Drug List (PDL). Preferred agents will be preferred with
clinical criteria.
Preferred
products will require a prior authorization request be submitted. Clinical
criteria must be met in order to be approved.
Non-preferred products will require prior authorization; for a
non-preferred product to be approved, failure with a designated number of
preferred agents and clinical criteria must be met.
4. Update the PDL to reflect the quarterly updates. The updates are listed
below:
PDL Additions
|
Advair Diskus
|
Inhaled Corticosteroids
Agents
|
Advair HFA
|
Inhaled Corticosteroids
Agents
|
Budesonide (generic
Pulmicort Respules)
|
Inhaled Corticosteroids
Agents
|
Dulera
|
Inhaled Corticosteroids
Agents
|
Omnitropecc
|
Growth Hormone Agents
|
Tobradex Ophthalmic Drops
|
EENT Antibacterial Agents
|
Xifaxan
|
Miscellaneous Antibacterial
Agents
|
Zomactoncc
|
Growth Hormone Agents
|
PDL Deletions
|
Albuterol HFA (generic
Proair HFA and Ventolin HFA)
|
Respiratory β-Agonists
|
Alvesco
|
Inhaled Corticosteroids
Agents
|
Cotempla XR
|
ADHD Agents
|
Fluticasone/salmeterol inhalation device (generic Advair Diskus)
|
Inhaled Corticosteroids
Agents
|
Kapvay*
|
ADHD Agents
|
Pulmicort Respules
|
Inhaled Corticosteroids
Agents
|
Tobramycin/Dexamethasone Ophthalmic Drops
(generic Tobradex)
|
EENT Antibacterials
|
cc Indicates drug will be
preferred with clinical criteria.
*
Drug was non-covered effective 1/28/2019.
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.