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




 


1. 
Require Dymista 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

AirDuo RespiClick

Respiratory Corticosteroids

Arnuity
Ellipta

Respiratory
Corticosteroids

Breo
Ellipta

Respiratory
Corticosteroids

Dymista

EENT
Antiallergic Agents

OmnitropeCC

Growth
Hormones

PDL Deletions

Azelastine/Fluticasone Nasal Spray (generic Dymista)

EENT Antiallergic Agents

Pazeo

EENT Antiallergic Agents




            CC Preferred with Clinical Criteria


 


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 on the Agency’s website 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:


 


Health Information Designs (HID)


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 HID. Additional information may be requested. Staff
physicians will review this information.


 


 

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Author: Editor
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