PDF Version
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 July 1, 2023, the
Alabama Medicaid Agency will:
1.
Require
Prior Authorization (PA) for methylphenidate transdermal patch (generic
Daytrana transdermal patch). Brand Daytrana will be added as preferred.
2.
Require Daytrana 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.
3. Update the PDL to reflect
the quarterly updates listed below:
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.