Preferred Drug List (PDL) and Pharmacy Quarterly Update

RE: Preferred Drug List (PDL) and Pharmacy Quarterly Update

Effective October 1, 2024, 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. Add the Asthma and Allergy Monoclonal Antibodies class to the PDL.Preferred products must meet clinical criteria to include FDA approved indications in order to be approved. Non-preferred products will require prior authorization (PA). 3. Require PA for generic bepotastine besilate ophthalmic solution, and generic budesonide/formoterol fumarate inhalation, including Breyna. Brand Bepreve and brand Symbicort 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.

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

PDL Additions
Fasenra CC	Asthma and Allergy Monoclonal Antibodies
Qvar RediHaler	Respiratory Corticosteroids
Tezspire CC	Asthma and Allergy Monoclonal Antibodies
Xolair CC	Asthma and Allergy Monoclonal Antibodies
PDL Deletions
bepotastine besilate ophthalmic solution (generic Bepreve)	Eye, Ear, Nose and Throat Antiallergic Agents
Breyna and budesonide/formoterol fumarate inhalation (generic Symbicort)	Respiratory Corticosteroids

^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 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:

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 © 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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