Preferred Drug List (PDL) and Pharmacy Quarterly Update


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 January 1, 2022, the Alabama Medicaid Agency will: 

1. Require Kazano, Nesina and Oseni 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.

2. Update the PDL to reflect the quarterly updates listed below:  

PDL Additions
Jentadueto XR Dipeptidyl Peptidase-4 Inhibitors
Kazano Dipeptidyl Peptidase-4 Inhibitors
Nesina Dipeptidyl Peptidase-4 Inhibitors
Oseni Dipeptidyl Peptidase-4 Inhibitors
Select-OB + DHA Prenatal Vitamins
Synjardy Sodium-Glucose Cotransport 2 Inhibitors
Synjardy XR Sodium-Glucose Cotransport 2 Inhibitors
Vitafol Fe+ Softgel Prenatal Vitamins
Vitafol-Nano Prenatal Tablet Prenatal Vitamins
Vitafol-OB Caplet Prenatal Vitamins
Vitafol-OB+DHA Prenatal Vitamins
Vitafol-One Softgel Prenatal Vitamins
Vitafol Prenatal
w/Iron Gummies
Soft Chew Prenatal Vitamins
Vitafol Ultra Softgel Prenatal Vitamins
Xigduo XR Sodium-Glucose Cotransport 2 Inhibitors

PDL Deletions
Actos Thiazolidinediones
Coumadin Oral Anticoagulants
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: 

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 Kepro. 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