TO:    Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes

 

Effective April 1, 2020, the Alabama Medicaid Agency will:

 

1.    Remove prior authorization from Tobramycin-Dexamethasone Ophthalmic Solution (generic Tobradex). Brand Tobradex will now require PA.

 

2.    Update the PDL to reflect the quarterly updates. The updates are listed below:

 

PDL Additions
Byetta	Incretin Mimetics
Bystolic	Beta Blockers
HemangeolCC	Beta Blockers
Incruse Ellipta	Inhaled Antimuscarinics
Stiolto Respimat	Respiratory Beta Agonists
Tobramycin-Dexamethasone Ophth. Solution	EENT Antibacterials
Victoza	Incretin Mimetics
PDL Deletions
Proventil HFA	Respiratory Beta Agonists
Seebri Neohaler	Inhaled Antimuscarinics
Tobradex	EENT Anitbacterials

                 ^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 Prior Authorization (PA) request form and criteria booklet should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. The PA request form can be completed and submitted electronically on the Agency’s website at https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

 

 

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.