PDF Version
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes
Effective October 1, 2019, the Alabama Medicaid Agency will:
1. Include preferred fibric acid derivatives, alendronate tablets, amitriptyline tablets, azathioprine tablets, hydroxychloroquine tablets, methotrexate tablets, pioglitazone tablets, and trazodone tablets in the mandatory three-month 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. Include the Antigout Agents in the Preferred Drug List (PDL).
3. Require Prior Authorization (PA) for colchicine tablets.
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 |
Citranatal Rx |
Prenatal Vitamins |
Farxiga |
Sodium-glucose Cotransport 2 Inhibitors |
Humalog Mix |
Insulins |
Invokamet |
Sodium-glucose Cotransport 2 Inhibitors |
Invokana |
Sodium-glucose Cotransport 2 Inhibitors |
Jardiance |
Sodium-glucose Cotransport 2 Inhibitors |
Jentadueto |
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors |
Mitigare |
Antigout |
Prempro |
Estrogens |
Tradjenta |
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors |
PDL Deletions |
Menest |
Estrogens |
Sklice |
Scabicides and Pediculicides |
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 should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. The PA request form can be completed and submitted electronically on the Agency’s website at https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.
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.