6/17/2014
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective July 1, 2014, the Alabama Medicaid Agency will:
1. Require prior authorization for payment of the below listed generics. The equivalent brand will be preferred with no PA.
· Use Dispense as Written (DAW) Code of 9 for these brand name products. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product to be Dispensed.
|
Generic |
Brand Name |
|
Lidocaine Topical Patch |
Lidoderm |
|
Dexmethylphenidate HCL |
Focalin |
|
Trospium Chloride |
Sanctura |
|
Diazapam Rectal Kit |
Diastat
Diastat Acudial |
|
Modafinil |
Provigil |
|
Levalbuterol Inhalation Solution |
Xopenex Inhalation Solution |
2. Update the Preferred Drug List (PDL) to reflect the quarterly updates. The updates are listed below:
|
PDL Additions |
|
Azelastine HCL
(generic Astelin) |
EENT Preparations/Antiallergic Agents |
|
Diastat |
Behavioral Health/Benzodiazepines |
|
Diastat Acudial |
Behavioral Health/Benzodiazepines |
|
Elidel |
Skin and Mucous Membrane/Miscellaneous |
|
Focalin |
Behavioral Health/Cerebral Stimulants-Agents used for ADHD |
|
Lidoderm |
Skin and Mucous Membrane/Antipruritics and Local Anesthetics |
|
Mentax |
Skin and Mucous Membrane/Antifungals |
|
Provigil |
Behavioral Health/Wakefulness Promoting Agents |
|
Sanctura |
Genitourinary Agents/Genitourinary Smooth Muscle Relaxants |
|
Sklice |
Skin and Mucous Membrane/Scabicides and Pediculicides |
|
Strattera |
Behavioral Health/Cerebral Stimulants-Agents used for ADHD |
|
Ulesfia |
Skin and Mucous Membrane/Scabicides and Pediculicides
|
|
Xopenex Inhalation Solution |
Respiratory/Selective Beta-2 Adrenergic Agonists |
|
Zovirax (cream only) |
Skin and Mucous Membrane/Antivirals |
|
PDL Deletions |
|
Advair |
Respiratory/Orally Inhaled Corticosteroids |
|
Advair HFA |
Respiratory/Orally Inhaled Corticosteroids |
|
Astelin |
EENT Preparations/Antiallergic Agents |
|
Dexmethylphenidate HCL
(generic Focalin) |
Behavioral Health/Cerebral Stimulants-Agents used for ADHD |
|
Diazapam Rectal Kit
(generic Diastat)
(generic Diastat Acudial) |
Behavioral Health/Benzodiazepines |
|
Levalbuterol Inhalation Solution
(generic Xopenex) |
Respiratory/Selective Beta-2 Adrenergic Agonists |
|
Lidocaine Topical Patch
(generic Lidoderm) |
Skin and Mucous Membrane/
Antipruritics and Local Anesthetics |
|
Modafinil |
Behavioral Health/ Wakefulness Promoting Agents |
|
Trospium Chloride
(generic Sanctura) |
Genitourinary Agents/
Genitourinary Smooth Muscle Relaxants |
|
Zovirax (ointment only) |
Skin and Mucous Membrane/Antivirals |
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.