PDF Version
TO: Pharmacies, Physicians, Physician Assistants,
Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental
Health Service Providers and Nursing Homes
RE: Preferred Drug List (PDL) Quarterly Update
Effective April 1,
2021, the Alabama Medicaid Agency will:
Require a Prior Authorization (PA) for pimecrolimus cream (generic Elidel cream). Brand Elidel cream will remain preferred.
Require Elidel cream to be billed with a Dispense as Written
(DAW) Code of 9: 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.
Update
the PDL to reflect the quarterly updates. The updates are listed
below:
PDL Additions
|
No additions
|
PDL Deletions
|
Omnitrope
|
Growth Hormone Agents
|
Pimecrolimus Cream
|
Skin & Mucous Membrane Agents-Misc.
|
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 Prior Authorization (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.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2021
American Medical Association and © 2021 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.