PDF Version
TO: Pharmacies, Physicians, Physician Assistants, Nurse
Practitioners, Oral Surgeons, Optometrists, Dentists,
Mental Health Service Providers and Nursing Homes
Effective April 1, 2015 the Alabama Medicaid Agency will:
1. Require prior authorization for payment of extended release guanfacine HCL (generic Intuniv). Brand Intuniv will continue to be preferred with no PA.
· Use Dispense as Written (DAW) Code of 9 for brand Intuniv. 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 |
|
Aerospan |
Respiratory/Orally Inhaled Corticosteroids |
|
Levemir |
Diabetic Agents/Insulins |
|
Tradjenta |
Diabetic Agents/Dipeptidyl Peptidase-4 Inhibitors |
|
PDL Deletions |
|
Glyset |
Diabetic Agents/Alpha-Glucosidase Inhibitors |
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 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 www.medicaid.alabama.gov 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.