Preferred Drug List (PDL) and Pharmacy Quarterly Update

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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 April 1, 2024, the Alabama Medicaid Agency (Medicaid) will:

1. Continue to monitor the stimulant shortage affecting ADHD medications.Should you need assistance, please contact Kepro at the number below for alternative prescribing and dispensing options.

2. Require Prior Authorization (PA) for generic insulin glargine, insulin glargine max solostar, insulin glargine solostar, insulin lispro, saxagliptin, saxagliptin-metformin, and tiotropium bromide. Brand Humalog, Kombiglyze XR, Lantus, Onglyza, and Spiriva Handihaler will remain preferred. Brand Toujeo Max Solostar and brand Toujeo Solostar will remain non-preferred.

3. Require Humalog, Kombiglyze XR, Lantus, Onglyza, and Spiriva Handihaler 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.

4. Implement clinical criteria for the Incretin Mimetics class. Preferred agents will be preferred with clinical criteria.Preferred products must meet clinical criteria to include FDA approved indications in order to be approved. Non-preferred products will require prior authorization.

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

PDL Additions
Apidra	Insulins
Apidra Solostar	Insulins
Bydureon Bcise CC	Incretin Mimetics
Ozempic CC	Incretin Mimetics
Rybelsus CC	Incretin Mimetics
PDL Deletions
Clindesse	Skin Mucous Membrane Agents Antibacterials
insulin glargine max solostar	Insulins
insulin glargine solostar	Insulins
saxagliptin HCL	Dipeptidyl Peptidase-4 (DPP-4)
saxagliptin-metformin ER	Dipeptidyl Peptidase-4 (DPP-4)
tiotropium bromide	Inhaled Antimuscarinics
Tudorza Pressair	Inhaled Antimuscarinics

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

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