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 April 1, 2025,
the Alabama Medicaid Agency (Medicaid) will:
1.
Continue to monitor the
stimulant shortage affecting ADHD medications. Should you need
assistance, please contact Acentra Health at the number below for alternative
prescribing and dispensing options.
2. Require
PA for generic liraglutide. Brand Victoza will remain preferred and will 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:
|
PDL
Additions
|
|
insulin lispro
|
Insulins
|
|
Otezla CC
|
Disease-Modifying Antirheumatic Agents
|
|
PDL Deletions
|
|
Apidra
|
Insulins
|
|
Apidra
Solostar
|
Insulins
|
|
Humalog
|
Insulins
|
|
liraglutide
|
Incretin
Mimetics
|
CC This agent will be preferred with clinical criteria
in place.
For additional PDL and
coverage information, visit our drug look-up site at
https://www.medicaid.alabamaservices.org/alportal/NDC%20Look%20Up/tabId/5/Default.aspx
.
The 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:
Acentra
Health
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 Acentra Health. 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 © 2025
American Medical Association and © 2025 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.