PDF Version
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective July 3, 2017, the Alabama Medicaid Agency will:
1. Include the Immunomodulatory Agents used to treat Multiple Sclerosis in the Preferred Drug List (PDL).
2. Require the Alabama Medicaid Pharmacy Opioid Dependence Treatment Agreement and Patient Consent Form be submitted for requests for opioid dependence drugs (Bunavail, Suboxone, Zubsolv, buprenorphine, and buprenorphine/naloxone). Prior authorization requests for opioid dependence medications must be accompanied by the Alabama Medicaid Pharmacy Opioid Dependence Treatment Agreement and Patient Consent Form and must be signed and dated by the patient and prescriber. The form can be found on the Agency website at
http://www.medicaid.alabama.gov/documents/9.0_Resources/9.4_Forms_Library/9.4.3_Consent_Forms/9.4.3_Form_391_Opioid_
Dependence_Patient_Consent_7-3-17.pdf
In addition to the patient consent form being submitted, Alabama Medicaid will also require attestation from the prescribing physician stating that the Prescription Drug Monitoring Program (PDMP) record for the patient has been reviewed prior to prescribing an opioid dependence medication. Urine drug screens will also be required for renewal requests.
3. Require prior authorization for Glatopa (glatiramer), the generic version of Copaxone. Copaxone will be preferred. Use Dispense as Written (DAW) Code of 9 for brand Copaxone. 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.
4. Update the PDL to reflect the quarterly updates. The updates are listed below:
|
PDL Additions
|
|
CitraNatal 90 DHA
|
Prenatal Vitamins
|
|
CitraNatal Assure
|
Prenatal Vitamins
|
|
CitraNatal B-Calm
|
Prenatal Vitamins
|
|
CitraNatal DHA
|
Prenatal Vitamins
|
|
CitraNatal Harmony
|
Prenatal Vitamins
|
|
Aubagio
|
Immunomodulatory
Agents
used to treat MS
|
|
Betaseron
|
Immunomodulatory
Agents
used to treat MS
|
|
Copaxone
|
Immunomodulatory
Agents
used to treat MS
|
|
Extavia
|
Immunomodulatory
Agents
used to treat MS
|
|
Gilenya
|
Immunomodulatory Agents
used to treat MS
|
|
Rebif
|
Immunomodulatory
Agents
used to treat MS
|
|
Tysabri
|
Immunomodulatory
Agents
used to treat MS
|
|
PDL Deletions
|
|
Vyvanse Chewable
|
ADHD
|
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 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.
The
Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes
descriptors, and other data are copyright © 2017 American Medical Association
and © 2017 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.