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) and Pharmacy Quarterly Update
Effective October 1, 2021, the Alabama Medicaid Agency will:
1. Require Prior Authorization (PA) for Azelastine/Fluticasone nasal spray (generic Dymista). Brand Dymista will be added as preferred.
2. Require Dymista to be billed with a Dispense as Written (DAW) Code of 9. 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.
3. Update the PDL to reflect the quarterly updates listed below:
PDL
Additions
|
AirDuo RespiClick
|
Respiratory Corticosteroids
|
Arnuity
Ellipta
|
Respiratory
Corticosteroids
|
Breo
Ellipta
|
Respiratory
Corticosteroids
|
Dymista
|
EENT
Antiallergic Agents
|
OmnitropeCC
|
Growth
Hormones
|
PDL Deletions
|
Azelastine/Fluticasone Nasal Spray (generic Dymista)
|
EENT Antiallergic Agents
|
Pazeo
|
EENT Antiallergic Agents
|
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.
The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2020 American Medical Association and © 2020 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.