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 November 19, 2018


  1. Add Xofluza® to the PDL as a preferred agent.

In anticipation of the upcoming flu season and the FDA-approval of Xofluza® on October 24th, the P&T Committee made an ad hoc recommendation during the November 7th meeting. The Committee recommended to follow the Centers for Disease Control and Prevention (CDC) statewide influenza epidemiology status for all available FDA-approved influenza antivirals (including Xofluza®) as soon as is possible to have the agents available for the upcoming flu season.  Therefore, Xofluza® was added to preferred status prior to the January 1, 2019, PDL update.


Effective January 1, 2019, the Alabama Medicaid Agency will:


  1. Require Prior Authorization (PA) for ritonavir (generic Norvir). Brand Norvir will not require prior authorization.

Use Dispense as Written (DAW) Code of 9 for brand Norvir. 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.


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

    PDL Additions


    Opiate Partial Agents


    Skin and Mucous Membrane, Anti-Inflammatory Agents

                   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 Services

P. O. Box 3210 Auburn, AL 36832-3210

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.