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

Effective October 1, 2022, the Alabama Medicaid Agency will:

Remove prior authorization (PA) from levalbuterol tartrate HFA (generic Xopenex HFA). Brand Xopenex HFA will now require PA.

Update the PDL to reflect the quarterly updates listed below:

PDL Additions

Clonidine Transdermal Patches (generic)

Central Alpha-Agonists


Growth Hormone Agents

Levalbuterol Tartrate HFA (generic)

Respiratory Beta-Adrenergic Agonists

PDL Deletions

QVAR Redihaler

Respiratory Corticosteroids

Xopenex HFA

Respiratory Beta-Adrenergic Agonists

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 at

Providers requesting PAs by mail or fax should send requests to:


Medicaid Pharmacy Administrative Services

P.O. Box 3570, Auburn, AL 36831

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.