March 20, 2014

State of Alabama
Press Release: Medicaid

Preferred Drug List Update

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


Effective April 1, 2014, the Alabama Medicaid Agency will:  


1.            Require prior authorization for payment of tobramycin inhalation solution (generic Tobi inhalation solution). Brand Tobi inhalation solution will be preferred with no PA.


·         Use Dispense as Written (DAW) Code of 9 for brand Tobi inhalation solution. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product to be Dispensed.


2.            Include preferred Proton Pump Inhibitors in the mandatory three-month maintenance supply program. Prescriptions for three month maintenance supply medications will not count toward the monthly prescription limit. A maintenance supply prescription will be required after 60 days stable therapy.


3.            Update the Preferred Drug List (PDL) to reflect the quarterly updates. The updates are listed below: 


PDL Additions

Tobi Inhalation Solution

Anti-infective Agents/Aminoglycosides

PDL Deletions


Diabetic Agents/Insulins

Levemir Flexpen

Diabetic Agents/ Insulins

Tobramycin Inhalation Solution           (Generic Tobi Inhalation Solution)

Anti-infective Agents/Aminoglycosides

Xopenex HFA

Respiratory/Beta-Adrenergic Agonists

For additional PDL and coverage information, visit our drug look-up site at


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 and should be utilized by the prescribing physician 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 prescribing physician believes medical justification should be considered, the physician must document this on the form or submit a written letter of medical justification along with the prior authorization 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 prior authorization procedures should be directed to the HID help desk at 1-800-748-0130.


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