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 April 1, 2022, the Alabama Medicaid Agency will:
1. Require Vascepa 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. Require Prior Authorization (PA) for Icosapent Ethyl (generic Vascepa). Brand Vascepa will be added as preferred.
3. Require Prior Authorization (PA) for Colchicine capsules (generic Mitigare). Brand Mitigare will remain non-preferred.
4. Treatments for COVID-19 will remain accessible and available through the pharmacy benefit on an outpatient basis through the Federal Public Health Emergency (PHE) period. Approval was granted in order to ensure any drug with a Food and Drug Administration (FDA)-approved or Emergency Use Authorization (EUA)-authorized indication for the treatment of COVID-19 be made available as preferred through the duration of the Federal PHE.
5. Update the PDL to reflect the quarterly updates listed below:
PDL Additions
Colchicine tablets (generic)
Antigout Agents
Vascepa
Miscellaneous Antilipemic Agents
PDL Deletions
Colchicine capsules (generic)
Antigout Agents
Colcrys
Antigout Agents
Icosapent Ethyl
Miscellaneous Antilipemic Agents
Providers requesting PAs by mail or fax should send requests to:
Kepro
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 © 2022 American Medical Association and © 2022 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.