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 January 1, 2023, the Alabama
Medicaid Agency will:
1. Require Pradaxa 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.
2. Require
Prior Authorization (PA) for Dabigatran (generic Pradaxa). Brand Pradaxa
will remain as preferred.
3. Update
the PDL to reflect the quarterly updates listed below:
PDL Additions
|
Ubrelvy*
|
Calcitonin Gene-related Peptide (CGRP)
Antagonists
|
PDL Deletions
|
Dabigatran (generic Pradaxa)
|
Oral
Anticoagulants
|
Trulicity
|
Incretin
Mimetics
|
*This agent will be preferred with clinical
criteria in place.
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
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:
Kepro
Medicaid
Pharmacy Administrative Services
P.O. Box 3570, Auburn,
AL 36831
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 Kepro.
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 © 2022 American Medical Association and © 2022 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.