Preferred Drug List (PDL) and Pharmacy 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


RE: Preferred Drug List (PDL) and Pharmacy Quarterly Update



Effective July 1, 2021, the Alabama Medicaid Agency will:


1.   Add pharmacy coverage for the shingles vaccine (Shingrix) for adults aged 50 and older. An administration fee of $5.00 will be allowed for each dose of shingles vaccine administered to covered recipients who meet the age requirements. Please refer to the Vaccine Billing Guidance for instructions on billing of the vaccine and the administration fee. Guidance can be found at:


2.   Remove Prior Authorization (PA) for ritonavir (generic Norvir). Brand Norvir will remain covered without prior authorization and will no longer be allowed to be billed with a Dispense as Written (DAW) Code of 9.


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

PDL Additions


CGRP Antagonists


Immunomodulatory Agents


Immunomodulatory Agents

Tobramycin Inhalation Solution (generic Tobi)


PDL Deletions


Immunomodulatory Agents

Bacitracin for Injection (generic)

Antibacterials, Miscellaneous


Respiratory Beta Agonists


Immunomodulatory Agents

Vyvanse Chewable Tablet



Antibacterials, Miscellaneous


*This agent will be preferred with clinical criteria in place.


For additional PDL and coverage information, visit our drug look-up site at


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


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.