TO: Pharmacies, Physicians, Physician
Assistants, Nurse Practitioners,
Oral Surgeons, Optometrists, Dentists, FQHCs,
Health Service Providers and Nursing Homes
January 3, 2017, the Alabama Medicaid
prior authorization (PA) for payment of mometasone
nasal spray (generic
prior authorization for generic tobramycin inhalation
Tobi and Kitabis). Brand Kitabis will remain
preferred without PA.
Use Dispense as Written
(DAW) Code of 9 for brand Kitabis. 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.
3. Update the PDL to reflect the quarterly updates. The updates are listed
Respiratory Beta-adrenergic Agonists
mometasone nasal spray (generic Nasonex)
tobramycin inhalation solution (generic Tobi and Kitabis)
cc Preferred with Clinical Criteria
For additional PDL and coverage information, visit our drug look-up site
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 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
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
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
directed to the HID help desk at 1-800-748-0130.
Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes
descriptors, and other data are copyright © 2016 American Medical Association
and © 2016 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.