TO:   Pharmacy and DME Providers

RE:   COVID-19 Unwinding - Changes to Pharmacy/DME

Per federal guidance, the COVID-19 public health emergency (PHE) will end on May 11, 2023. Therefore, some flexibilities the Alabama Medicaid Agency (Medicaid) implemented due to the COVID-19 PHE will end at this time. Medicaid intends to keep providers updated on changes that will be forthcoming during the return to normal operations.  Medicaid is working with the Centers for Medicare and Medicaid Services (CMS) to prepare to end some flexibilities implemented during the COVID-19 PHE. Medicaid will provide notice of changes through separate notices via State Plan notice, Administrative Code notice, waiver notice, or provider ALERTs. 

Below are some changes that are coming up soon that may impact Pharmacy and/or DME providers:

Effective June 1, 2023:

• Alabama Medicaid will discontinue the universal prior authorization number (9999999999) to override early refill,maximum units, and mandatory three-month maintenance supply for outpatient pharmacy claims. 

• Alabama Medicaid will resume routine edits and criteria requirements for outpatient pharmacy claims. The cumulative daily Morphine Milligram Equivalent (MME) edit will resume phase down at a future time; prior notice will be provided through a subsequent ALERT. 
• Alabama Medicaid will resume routine edits and criteria for Durable Medical Equipment (DME) requests, including:

·        Prior Authorization for DME must be received within 30 days after the equipment is dispensed, 

·        30-day extensions will no longer be provided on prior authorizations, and

·        A prescription/order for DME items must be presented to the provider/fiscal agent within 90 days from the date it was written.

As noted in previous ALERTs:

• Effective May 12, 2023:  Recipient signatures are required to be kept on file as verification that the recipient was present on the date of service for which the provider seeks payment. More information can be found in the Alabama Administrative Code, Chapter 1, Rule No. 560-X-1-.18 “Provider and Recipient Signature Requirements”.   
• Effective June 1, 2023:  Providers should no longer bill the CR modifier for COVID-19 related services or equipment. 
• Effective June 1, 2023:  Medicaid will resume the referral requirements for EPSDT visits and prior authorizations that require EPSDT referrals. 
• Effective October 1, 2024:  Copayments will be reinstated for applicable services and recipients.
• Alabama Medicaid will continue to cover COVID-19 tests and vaccines. Any future changes to the current policy will be sent through a subsequent ALERT.

Please continue to visit the Alabama Medicaid website for up-to-date information related to the ‘unwinding’ process. If you have questions, please contact the Provider Assistance Line at (800) 688-7989, or Medicaid’s Pharmacy and DME department at (334) 242-5050.

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