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 July 1, 2026, the Alabama Medicaid Agency (Medicaid) will:
- Remove the Dispense as Written (DAW) Code of 9 from Elidel.
- Discontinue posting the following documents to the Medicaid
website:
a. Alabama
Medicaid Agency Alphabetical Preferred Drug List
b. Alabama
Medicaid Agency Preferred Drug List By Therapeutic Category
- Continue to update the Alabama Medicaid PDL Reference Tool,
which now includes Therapeutic Category, on a quarterly basis (January,
April, July and October) of each year.
- Update Prior Authorization (PA) Form 373 and its instruction
document on the Medicaid website. The updated form and instruction documents are located at:
https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.
- Update the PDL to reflect the quarterly updates
listed below:
CC This agent will be preferred with clinical criteria in place.
Pharmacy
Audit Reminders:
Federal regulations
require that administrative audits of provider billing practices be performed
on a routine basis. The primary focus of these retrospective reviews is to
monitor and improve the accuracy of Medicaid payments and to ensure compliance
with policies and procedures established by Medicaid, as well as all applicable
federal and state laws. In addition to standard audits performed as outlined in
Chapter 27 of the Provider Billing Manual, Medicaid will be monitoring claims
for the appropriate use of Other Coverage Code (OCC) and Dispense As Written
(DAW) codes. Pharmacy providers are required to maintain supporting
documentation on all claims utilizing OCC-3 (Other Coverage Billed - Claim Not
Covered) and DAW-8. Failure to maintain appropriate supporting documentation
may result in claim recoupments.
As a reminder, for
patients with multiple insurances, Medicaid is always the payor of last resort.
Pharmacy providers should file a patient’s primary insurance and obtain
approval or denial, prior to filing Medicaid. A “Prior Authorization Required”
response from the primary insurer does not constitute a denial and will not be
accepted if utilizing an Other Coverage Code (OCC)-3 on a pharmacy claim.
For detailed guidance,
please refer to Provider Billing Manual (Chapter 27- Pharmacy) at:
https://medicaid.alabama.gov/content/gated/7.6.1G_Provider_Manuals/7.6.1.4G_Oct2025/Oct25_27.pdf.
Questions may be
directed to the Clinical Audit Pharmacist Specialist with the Pharmacy Services
Division : Tara Queen, RPh, MSL, via phone (334) 353-4593 or email tara.queen@medicaid.alabama.gov.
For additional PDL and
coverage information, visit our drug look-up site at
https://www.medicaid.alabamaservices.org/alportal/NDC%20Look%20Up/tabId/5/Default.aspx.
The 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:
Acentra Health
Medicaid Pharmacy Administrative Services
P.O. Box 3570, Auburn, AL 36831
Fax: (800) 748-0116
Phone: (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 Acentra Health. 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 © 2026 American Medical Association
and © 2026 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.