June 8, 2015

State of Alabama
Press Release: Medicaid

PDL Quarterly Updates

PDF Version

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

Effective July 1, 2015, the Alabama Medicaid Agency will:


  1. Require prior authorization (PA) for payment of non-preferred brand Oral Anticoagulants.
  2. Require prior authorization for payment of clonidine HCL ER (generic Kapvay). Brand Kapvay will be preferred with no PA.

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

  1. Require prior authorization for payment of dexmethylphenidate HCL ER (generic Focalin XR).  Brand Focalin XR will continue to be preferred with no PA.

·         Use Dispense as Written (DAW) Code of 9 for brand Focalin XR.  DAW Code of 9 indicates the following: Substitution Allowed by Prescriber by Plan Requests Brand – Patient’s Plan Requested Brand Products to be dispensed.

  1. Remove prior authorization from zafirlukast (generic Accolate).  Brand Accolate will now require PA.
  2. Remove prior authorization from levalbuterol inhalation solution (generic Xopenex Inhalation Solution).  Brand Xopenex Inhalation Solution will now require PA.
  3. Update the Preferred Drug List (PDL) to reflect the quarterly updates. The updates are listed below: 

PDL Additions

Advair Diskus

Orally Inhaled Corticosteroids


Oral Anticoagulants


Dipeptidyl Peptidase-4 Inhibitors

Janumet XR

Dipeptidyl Peptidase-4 Inhibitors


Dipeptidyl Peptidase-4 Inhibitors


Cerebral Stimulants-Agents for ADHD/Central Alpha Agonists

PDL Deletions


Leukotriene Modifiers

Flovent Diskus

Orally Inhaled Corticosteroids

Flovent HFA

Orally Inhaled Corticosteroids


Dipeptidyl Peptidase-4 Inhibitors

Xopenex Inhalation Solution

Selective Beta-2 Adrenergic Agonists


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.


  • For more information, visit http://medicaid.alabama.gov
  • For more state-wide press releases, click here