Frequently Asked Questions

Pharmacy and Drugs - Providers

In FY 2015, Medicaid's Pharmacy Program paid for nearly 7 million prescriptions for approximately 600,000 recipients.
Below are some questions people often ask about the Medicaid Pharmacy program.  Click on the questions to see the answers:

Information about Pharmacy Services can be found on the Alabama Medicaid website at www.medicaid.alabama.gov under Programs>Pharmacy Services.
Preferred drugs and non-preferred drugs are listed on the PDL Reference Tool which can be found on the Alabama Medicaid website under Programs > Pharmacy Services > Preferred Drug List. Updates are made to the Preferred Drug List on a quarterly basis.
Non-preferred drugs on the Preferred Drug List require prior authorization. Drugs that require a PA but are not included on the PDL are included in the Criteria/Instruction Booklet which can be found under Programs > Pharmacy Services > Pharmacy Forms > Form 369 Instructions.
Retroactive PA requests can be submitted if they are requested within 90 days of the recipient's eligibility award date. These requests can be approved back to the recipient's eligibility effective date. For Medicaid providers that submit claims in batch, a retroactive override or PA may be given up to seven calendar days after the date the prescription is dispensed. All existing criteria must be met in order for the override or PA to be granted.
The Maximum Unit List can be found on the Alabama Medicaid website under Programs > Pharmacy Services > Billing > Policy Information.
If a prescription (or its subsequent refill) to be paid by Medicaid exceeds the drug's maximum unit limit allowed per month, the prescriber or pharmacist must request an override for the entire prescribed quantity. If the override is denied, then the excess quantity above the maximum unit limit is non-covered, and the recipient can be charged as a cash recipient for that amount in excess of the maximum unit limit. In other words, for a prescription to be to be "split billed" (the maximum unit allowed paid by Medicaid and the remainder of the prescribed quantity paid by the patient), a maximum unit override must be requested by the provider, and must be denied to be deemed non-covered. Note: A provider's failure or unwillingness to go through the process of obtaining an override does not constitute a non-covered service.
Telephone prescriptions are allowed except for Schedule II drugs.
Yes. A recipient may pay cash for a prescription if the prescription is non-covered by Medicaid, or if the recipient is informed prior to payment that the service may be a covered service. Please refer to Chapter 7.1.9 of the Provider Billing Manual for additional information related to billing recipients.
Alabama Medicaid may not cover drugs that are excluded from coverage by the Omnibus Budget Reconciliation Act of 1990 (OBRA 90), do not have a federal rebate, are considered DESI (FDA less than effective), or that have an obsolete NDC. For more information, please refer to Chapter 16 of the Administrative Code.
For a brand name drug that has an exact generic equivalent to be dispensed, the provider must request an override via the Pharmacy PA contractor that documents medical necessity for the need of the brand rather than the available generic. For more information, please refer to Chapter 16 of the Administrative Code, available on the Agency's website under "Resources."
National Drug Code.
Contact HP Enterprise Services Provider Enrollment unit at 1(888) 223-3630 or go to the Provider Enrollment page on the Agency's website at www.medicaid.alabama.gov and look under Contacts > Provider Contacts.