PDL Quarterly Update



TO:      Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes


Effective October 2, 2017, the Alabama Medicaid Agency will:


  1. Include pancreatic enzymes and vitamin B-12 injection in the mandatory three-month maintenance supply program. 

Prescriptions for three-month maintenance supply medications will not count toward the monthly prescription limit.  A maintenance supply prescription will be required after 60 days’ stable therapy.  Please see the website for a complete listing of maintenance supply medications.


  1. Require Prior Authorization (PA) for ezetimibe (generic Zetia), methylphenidate ER (generic Concerta), and moxifloxacin (generic Vigamox). Brand Concerta and Zetia will be added as preferred without PA.  Brand Vigamox will remain preferred. 

Use Dispense as Written (DAW) Code of 9 for brand Concerta, Vigamox and Zetia. 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.


  1. Update the PDL to reflect the quarterly updates. The updates are listed below: 


PDL Additions

Adzenys XR

ADHD Agents


Platelet Aggregation Inhibitors


ADHD Agents


Oral Anticoagulants


RAAS Inhibitors

Ofloxacin Otic Drops

EENT Antibacterials


Oral Anticoagulants


Oral Anticoagulants


Cholesterol Absorption Inhibitors

PDL Deletions

Bactroban Nasal

EENT Antibacterials


EENT Antibacterials

Ezetimibe (generic Zetia)

Cholesterol Absorption Inhibitors

Methylphenidate ER (generic Concerta)

ADHD Agents


EENT Antibacterials

Moxifloxacin (generic Vigamox)

EENT Antibacterials


Hepatitis C Antivirals

For additional PDL and coverage information, visit our drug look-up site at


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 and should be utilized by the prescriber 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

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.


Policy questions concerning this provider notice should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding PA procedures should be directed to the HID help desk at 1-800-748-0130.