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) 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: https://medicaid.alabama.gov/documents/4.0_Programs/4.3_Pharmacy-DME/4.3.11_Vaccine_Admin/4.3.11_Vaccine_Administration_Guidance_10-15-19.pdf.
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
|
Ajovy*
|
CGRP Antagonists
|
Avonex
|
Immunomodulatory Agents
|
Tecfidera
|
Immunomodulatory Agents
|
Tobramycin Inhalation Solution (generic Tobi)
|
Aminoglycosides
|
PDL Deletions
|
Aubagio
|
Immunomodulatory
Agents
|
Bacitracin
for Injection (generic)
|
Antibacterials,
Miscellaneous
|
Bevespi
|
Respiratory
Beta Agonists
|
Gilenya
|
Immunomodulatory
Agents
|
Vyvanse
Chewable Tablet
|
ADHD
|
Xifaxan
|
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 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.