PDF Version
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:
1.
Remove prior authorization (PA) from
levalbuterol
tartrate HFA (generic Xopenex HFA). Brand Xopenex HFA
will now require PA.
2. Update the PDL to reflect
the quarterly updates listed below:
|
PDL
Additions
|
|
Clonidine Transdermal Patches (generic)
|
Central Alpha-Agonists
|
|
Genotropin
|
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 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 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:
Kepro
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.