September 4, 2015

State of Alabama
Press Release: Medicaid

PDL Quarterly Updates

PDF Version


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

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


  1. Require prior authorization (PA) for payment of clonidine patches (generic Catapres-TTS Patches). Brand Catapres-TTS will be preferred with no PA.

·         Use Dispense as Written (DAW) Code of 9 for brand Catapres-TTS. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand. This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted, but the Plan requests the brand product to be dispensed.

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

PDL Additions


Central Alpha-Agonists


EENT Preparations/Antibacterials


Dipeptidyl Peptidase-4 Inhibitor

Kombiglyze XR

Dipeptidyl Peptidase-4 Inhibitor


Dipeptidyl Peptidase-4 Inhibitor


Dipeptidyl Peptidase-4 Inhibitor

PDL Deletions

Advair Diskus

Respiratory/Orally Inhaled Corticosteroids

Pulmicort Flexhaler

Respiratory/Orally Inhaled Corticosteroids


Respiratory/Orally Inhaled Corticosteroids

 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 prescriber 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 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 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 PA procedures should be directed to the HID help desk at 1-800-748-0130.


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