Alabama Medicaid: Pharmacy Changes ALERT Effective January 1, 2014
Pharmacy Changes Effective January 1, 2014
December 6, 2013
TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, Hospitals and Nursing Homes
Effective January 1, 2014, the Alabama Medicaid Agency will:
- Limit the number of outpatient pharmacy prescriptions to five total drugs (including up to four brands) per month for adults. Children under 21 and nursing home recipients are excluded. Allowances will be made for up to five additional (10 total) prescriptions for brand and generic antipsychotics, antiretrovirals, and anti-epileptic drugs. In no case can total prescriptions exceed 10 per month/per recipient.
- Implement a mandatory three-month maintenance supply program for selected medication classes. A maintenance supply prescription will only be counted towards the prescription limit in the month in which it is filled, and will be required after 60 days stable therapy.
The selected classes include:
- Reimburse for agents used to promote smoking cessation in accordance with mandatory coverage required under the Affordable Care Act. These agents will require prior authorization and the recipient must enroll in the Alabama Department of Public Health Quitline. More information can be found at www.medicaid.alabama.gov under the Pharmacy/DME page.
- Cover benzodiazepines and barbiturates (under the PDL) for eligible recipients in accordance with mandatory coverage required under the Affordable Care Act.
- Require prior authorization for payment of generic budesonide (Pulmicort). Brand Pulmicort Respules will be preferred with no PA. Use Dispense as Written (DAW) Code of 9 for brand Pulmicort Respules. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product to be Dispensed.
- Update the Preferred Drug List (PDL) to reflect the recent Pharmacy and Therapeutics (P&T) Committee’s recommendations as well as quarterly updates.
The updates are listed below:
For additional PDL and coverage information, visit our drug look-up site here
The PA request form and criteria booklet, as well as a link for a PA request form that can be completed and submitted electronically online, can be found on the Agency’s website at www.medicaid.alabama.gov and should be utilized by the prescribing physician or the dispensing pharmacy when requesting a PA. 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
Incomplete PA requests or those failing to meet Medicaid criteria will be denied. If the prescribing physician believes medical justification should be considered, the physician must document this on the form or submit a written letter of medical justification along with the prior authorization form to HID. Additional information may be requested. Staff physicians will review this information.
Policy questions concerning this provider notice should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding prior authorization procedures should be directed to the HID help desk at 1-800-748-0130.