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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 January 1, 2026, the Alabama Medicaid Agency (Medicaid) will:

1. Require prior authorization (PA) for glycerol phenylbutyrate (generic Ravicti). Brand Ravicti will not require a PA 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.

2. Require prior authorization for clemastine syrup (generic Tavist), conjugated estrogens tablets (generic Premarin tablets), fluticasone/vilanterol (generic Breo Ellipta), and mirabegron (generic Myrbetriq). Brand Breo Ellipta, Myrbetriq, and Premarin tablets will be preferred and will be billed with a 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:

^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 Prior Authorization Request Form (Form 369) and criteria booklet (Form 369/389 Instructions) should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. The 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.