Preferred Drug List (PDL) Quarterly Update


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

Effective July 2, 2018, the Alabama Medicaid Agency will:

1.    Implement a Prospective DUR Ingredient Duplication Edit.  The new edit will review claims history for possible ingredient duplication and deny claims when simultaneous use of medications containing the same active ingredient and prescribed by different prescribers are detected. The drugs to be included in the ingredient duplication edit are:

•    Pregabalin (ex. Lyrica)
•    Gabapentin (ex. Neurontin)

The new ingredient duplication edit will not be able to be overridden with conflict/intervention/outcome codes but will require a manual override.  Requests should be submitted to Health Information Designs using Form 409 (Override Request Form).  Medical justification is required for patients to be on 2 strengths/formulations of the same medication at the same time by different prescribers and must be included on the form. The form can be found at

2.    Include the Complement Inhibitors used to treat Hereditary Angioedema (HAE) in the Preferred Drug List (PDL).

3.    Remove prior authorization from esomeprazole magnesium (generic Nexium). Brand Nexium will now require PA.

4.    Require Prior Authorization (PA) for darifenacin ER (generic Enablex) and glatiramer (generic Copaxone). Brand Enablex will be added as preferred without PA.  Brand Copaxone will remain preferred.
Use Dispense as Written (DAW) Code of 9 for brand Enablex and 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.

5.    Suboxone films will be preferred with clinical criteria. Generic versions will be non-preferred. Use DAW Code of 9 for brand Suboxone films.  Clinical criteria must be met in order to be approved.  Non-preferred products will continue to require prior authorization; for a non-preferred product to be approved, failure with a designated number of preferred agents and clinical criteria must be met. 

6.    Update the PDL to reflect the quarterly updates. The updates are listed below:

            PDL Additions

CitraNatal RX

Prenatal Vitamins


Genitourinary Smooth Muscle Relaxants

Esomeprazole Magnesium (generic Nexium)

Proton-Pump Inhibitors




Opiate Partial Agonists

Vyvanse Chewable Tablets


PDL Deletions

Darifenacin ER (generic Enablex)

Genitourinary Smooth Muscle Relaxants


Respiratory Corticosteroids


Multiple Sclerosis

Glatiramer (generic Copaxone)

Multiple Sclerosis


Proton-Pump Inhibitors


Selective Serotonin Agonists


HCV Antivirals

Viekira Pak

HCV Antivirals

                 CC Preferred with Clinical Criteria

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 Service
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 © 2018 American Medical Association and © 2018 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.