Preferred Drug List (PDL) and Pharmacy Quarterly Update

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, 2022, the Alabama Medicaid Agency will:

1. Require Kazano, Nesina and Oseni 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.

2. Update the PDL to reflect the quarterly updates listed below:

PDL Additions

Jentadueto XR Dipeptidyl Peptidase-4 Inhibitors

Kazano Dipeptidyl Peptidase-4 Inhibitors

Nesina Dipeptidyl Peptidase-4 Inhibitors

Oseni Dipeptidyl Peptidase-4 Inhibitors

Select-OB + DHA Prenatal Vitamins

Synjardy Sodium-Glucose Cotransport 2 Inhibitors

Synjardy XR Sodium-Glucose Cotransport 2 Inhibitors

Vitafol Fe+ Softgel Prenatal Vitamins

Vitafol-Nano Prenatal Tablet Prenatal Vitamins

Vitafol-OB Caplet Prenatal Vitamins

Vitafol-OB+DHA Prenatal Vitamins

Vitafol-One Softgel Prenatal Vitamins

Vitafol Prenatal
w/Iron Gummies
Soft Chew Prenatal Vitamins

Vitafol Ultra Softgel Prenatal Vitamins

Xigduo XR Sodium-Glucose Cotransport 2 Inhibitors

PDL Deletions

Actos Thiazolidinediones

Coumadin Oral Anticoagulants

Providers requesting PAs by mail or fax should send requests to:

Kepro

Medicaid Pharmacy Administrative Services

P. O. Box 3210 Auburn, AL 36832-3210

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 © 2021 American Medical Association and © 2021 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply

Public link

Please use the above public link if you want to share this noodl on another website.