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, 2023,
the Alabama Medicaid Agency will:
1. Update the PDL to reflect
the quarterly updates listed below:
PDL
Additions
|
Clindesse
|
Skin & Mucous Membrane Agents: Antibacterials
|
Trulicity
|
Incretin Mimetics
|
PDL Deletions
|
Capex Shampoo
|
Skin & Mucous Membrane Agents:
Corticosteroids
|
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 © 2023
American Medical Association
and © 2023 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.