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 July 1, 2026, the Alabama Medicaid Agency (Medicaid) will:

1. Remove the Dispense as Written (DAW) Code of 9 from Elidel.

1. Discontinue posting the following documents to the Medicaid website:

a. Alabama Medicaid Agency Alphabetical Preferred Drug List

b. Alabama Medicaid Agency Preferred Drug List By Therapeutic Category

1. Continue to update the Alabama Medicaid PDL Reference Tool, which now includes Therapeutic Category, on a quarterly basis (January, April, July and October) of each year.

1. Update Prior Authorization (PA) Form 373 and its instruction document on the Medicaid website. The updated form and instruction documents are located at:

https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx .

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

^CC This agent will be preferred with clinical criteria in place.

Pharmacy Audit Reminders :

Federal regulations require that administrative audits of provider billing practices be performed on a routine basis. The primary focus of these retrospective reviews is to monitor and improve the accuracy of Medicaid payments and to ensure compliance with policies and procedures established by Medicaid, as well as all applicable federal and state laws. In addition to standard audits performed as outlined in Chapter 27 of the Provider Billing Manual, Medicaid will be monitoring claims for the appropriate use of Other Coverage Code (OCC) and Dispense As Written (DAW) codes. Pharmacy providers are required to maintain supporting documentation on all claims utilizing OCC-3 (Other Coverage Billed - Claim Not Covered) and DAW-8. Failure to maintain appropriate supporting documentation may result in claim recoupments.

As a reminder, for patients with multiple insurances, Medicaid is always the payor of last resort. Pharmacy providers should file a patient's primary insurance and obtain approval or denial, prior to filing Medicaid. A "Prior Authorization Required" response from the primary insurer does not constitute a denial and will not be accepted if utilizing an Other Coverage Code (OCC)-3 on a pharmacy claim.

For detailed guidance, please refer to Provider Billing Manual (Chapter 27- Pharmacy) at : https://medicaid.alabama.gov/content/gated/7.6.1G_Provider_Manuals/7.6.1.4G_Oct2025/Oct25_27.pdf .

Questions may be directed to the Clinical Audit Pharmacist Specialist with the Pharmacy Services Division : Tara Queen, RPh, MSL, via phone (334) 353-4593 or email [email protected] .

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 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 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: (800) 748-0116

Phone: (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.

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