Preferred Drug List (PDL) Quarterly Update


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

Effective October 1, 2018, the Alabama Medicaid Agency will:

1. Include preferred insulins in the mandatory three-month maintenance supply program.

Prescriptions for three-month maintenance supply medications will not count toward the monthly prescription limit. A maintenance supply prescription will be required after 60 days’ stable therapy. Please see the website for a complete listing of maintenance supply medications.

2. Require Prior Authorization (PA) for generic hydroxyprogestrone injection (generic Makena). Brand Makena will not require prior authorization.  
Use Dispense as Written (DAW) Code of 9 for brand Makena. 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 below:

PDL Additions

Cotempla XR

Agents used for ADHD

Darifenacin (generic Enablex)

Genitourinary Smooth Muscle Relaxants-Antimuscarinics

Moxifloxacin Drops (generic Vigamox)

EENT- Antibacterials

Olopatadine (generic Patanase)

EENT- Antiallergic Agents


Agents used for ADHD

Qvar Redihaler

Respiratory Corticosteroids


Genitourinary Smooth Muscle Relaxants-Antimuscarinics


Platelet Aggregation Inhibitors

PDL Deletions


Agents used for ADHD


Genitourinary Smooth Muscle Relaxants-Antimuscarinics


EENT- Antiallergic Agents


Agents used for ADHD


EENT- Antibacterials

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 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 © 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.