December 4, 2014

State of Alabama
Press Release: Medicaid

PDL Quarterly Updates

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

Effective January 5, 2015, the Alabama Medicaid Agency will:


1.    Require prior authorization for payment of atovaquone oral suspension (generic Mepron oral suspension). Brand Mepron oral suspension will be preferred with no PA.

·        Use Dispense as Written (DAW) Code of 9 for brand Mepron oral suspension. 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.    Update the Preferred Drug List (PDL) to reflect the quarterly updates. The updates are listed below: 

PDL Additions

Humalog Mix 50-50

Anti-diabetic Agents/Insulins

Humalog Mix 75-25

Anti-diabetic Agents/Insulins


Anti-infective Agents/Antiprotozoals, Miscellaneous


Anti-diabetic Agents/Insulins

Novolog Mix 75-25

Anti-diabetic Agents/Insulins

PDL Deletions


Anti-infective Agents/Antifungals, Miscellaneous


Anti-infective Agents/Interferons

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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