Alabama Administrative Code

(1) A pharmacy must be operating under a permit or license to dispense drugs as issued by the Alabama State Board of Pharmacy or appropriate authority in the state where the service is rendered. (2) A pharmacy applicant must submit and have approved a pharmacy agreement signed by…

(1) A physician may dispense drugs under the Alabama Medicaid Program if he has a current agreement to dispense drugs with the Alabama Medicaid Agency. (2) Dispensing physicians are enrolled as drug providers in the pharmacy program only where adequate pharmacy services are not a…

Hospitals. Payment for drugs for inpatient hospital care under the Title XIX Program is based on reasonable cost which allows payment (per diem) not to exceed Medicare levels. Author: Larry A. Tatum Notes Ala. Admin. Code r. 560-X-16-.04 Rule effective October 1, 1982. Amended: E…

(1) (a) The nursing facility must meet the State and Federal Standards and the Title XIX rules and regulations for pharmacy services. (b) The payment limit for prescription drugs dispensed to patients confined in the Long Term Care facilities must not exceed the upper limits as c…

(1) Medicaid pays for certain legend and non-legend drugs prescribed by practitioners legally licensed by the state of Alabama to prescribe the drugs authorized under the program and dispensed and/or administered by a licensed pharmacist or licensed authorized physician in accord…

(1) Under State and Federal regulations, a pharmacy must sign an agreement with Alabama Medicaid Agency. However, when a recipient is in another state and requires service, the following procedure has been adopted. (2) Pharmacies Bordering Alabama (a) Pharmacies bordering Alabama…

(1) Injectable drugs administered by physicians and outpatient hospitals are allowable. (2) Claims for injectable medication administered by the physician should be made on the physician's claim form and submitted to the fiscal agent for payment. (3) Claims for injectable medicat…

Author: Louise Jones, Associate Director, Program Management Unit Notes Ala. Admin. Code r. 560-X-16-.09 Rule effective October 1, 1982. Amended: Effective April 14, 1992. Amendments to this rule filed March 11, 1994 were disapproved by Joint Committee on Administrative Regulatio…

(1) Medicaid recipients are required to pay the designated CO-pay amount for each prescription filled and each refill. (2) The cost-sharing fee does not apply to family planning drugs and supplies, or to drugs prescribed for recipients under 18 years of age, recipients who are in…

(1) Federal regulations require pharmacy consultant services in nursing facilities as a condition of participation. This requirement recognizes the professional status of the pharmacist and makes him an integral part of the health care team. (2) The requirement that there be phar…

(1) Over-the-counter medications/products require a signed prescription from a physician or other practitioner legally licensed by the State of Alabama to prescribe the drugs authorized under the program. (2) Over-the-counter medications/products must be dispensed by a licensed M…

Notes Ala. Admin. Code r. 560-X-16-.13 Rule effective October 1, 1982. Repealed by Alabama Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024, eff. 7/15/2024. Statutory Authority: The Alabama Medicaid Agency Contract with Fiscal Agent for payment of claims.

Notes Ala. Admin. Code r. 560-X-16-.14 Rule effective October 1, 1982. Repealed: Effective April 14, 1992.

For claim filing limitations, refer to Chapter 1, Rule 560-X-1-.17. Author: Sam T. Hardin Notes Ala. Admin. Code r. 560-X-16-.15 Rule effective October 1, 1982. Amended: Effective November 11, 1985. Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401,…

Refer To Rules 560-X-1-.17 And 560-X-1-.18. Author: Charles A. Reasner Notes Ala. Admin. Code r. 560-X-16-.16 Rule effective October 1, 1982. Amended: Effective March 12, 1988. Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.

The recipient may be placed on restriction who has abused and/or over-utilized pharmacy and/or physician services. The procedure to place an individual on restriction and limit the individual to a pharmacy and a physician is stated in Chapter 4 on S/UR in this Code. Author: Notes…

Notes Ala. Admin. Code r. 560-X-16-.18 Rule effective October 1, 1982. Amended: Effective April 14, 1992. Repealed by Alabama Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024, eff. 7/15/2024. Author: Larry A. Tatum Statutory Authority: State Plan, Attachment 3.1A; T…

Notes Ala. Admin. Code r. 560-X-16-.19 Rule effective October 1, 1982. Amended: Effective May 9, 1984; April 14, 1992. Amended: Filed January 6, 1998; effective February 10, 1998. Repealed by Alabama Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024, eff. 7/15/2024. …

(1) Prescriptions should be written to provide a sufficient amount of medication necessary for the duration of the illness or an amount sufficient to cover the interval between physician's visits. A prescription shall not be split into small units and submitted as separate claims…

(1) Prescriptions will have a maximum of no more than eleven (11) refills for non controlled prescriptions or five (5) refills for Control III-V prescriptions authorized. (2) Physicians are urged to designate refills or indicate non-refills on all Title XIX (Medicaid) prescriptio…

Notes Ala. Admin. Code r. 560-X-16-.22 Rule effective October 1, 1982. Amended: Effective November 10, 1987; April 14, 1992. Repealed by Alabama Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024, eff. 7/15/2024. Authors: Janet B. Young; Larry A. Tatum Statutory Autho…

In accordance with the Medicaid Drug Amendments contained in the Omnibus Budget Reconciliation Act of 1990, (Public Law 101-508), the following shall apply: (1) The Medicaid Agency shall provide, by not later than January 1, 1993, for a Drug Utilization Review (DUR) Program for c…

(1) Prospective DUR (PRODUR) is required at the point of sale or distribution before each prescription is filled or delivered to a Medicaid recipient. It must include screening, patient counseling, and patient profiles. (2) Screening - The review must include screening for potent…

(1) The retrospective DUR Program reviews, analyzes and interprets patterns of recipient drug usage by applying criteria and standards, developed by the DUR Board, against claims data through periodic examination to identify patterns of fraud and abuse, gross overuse, and inappro…

(1) The purpose of this program is to educate practitioners on common drug therapy problems to improve prescribing and dispensing practices. (2) Drug use criteria and standards, established by the DUR Board shall be applied to the drug database after the medication is dispensed. …

(1) The Alabama Medicaid Agency will utilize a preferred drug list for determination of drugs available for reimbursement under the Medicaid Program. For reimbursement under the Medicaid Program, use of the Preferred Drug list is mandatory. Drugs not included on the list may be a…

(1) The use and payment of drug items may be restricted and require prior authorization. The Alabama Medicaid Agency will utilize the Pharmacy and Therapeutics Committee to review and recommend drugs for prior authorization. (2) Drug class is defined as a therapeutic group of pha…

(1) The DUR Board must submit an annual report to the Medicaid Agency containing information specified by the state. The Agency must submit, annually, a report to the Secretary of Health and Human Services through the HCFA Regional Office that incorporates the DUR Board Report. I…

(1) Reimbursement for disease specific drugs related to the recipient's terminal illness and drugs related to the terminal illness found on the Hospice Palliative Drug List (HPDL) are included in the per diem for hospice covered services and will not be reimbursed through the Med…

In order to be paid for providing blood clotting factor to Alabama Medicaid recipients, the provider must agree to provide, at the minimum, the following clinically appropriate items and services to their patients with hemophilia and blood clotting factor-related diseases: (1) Ho…

The information contained herein sets forth policies and procedures for providing eye care services under the Alabama Medicaid Program. (1) Participation. Only in-state and borderline out-of-state eye care services providers (within a 30-mile radius of the state line) who meet en…

(1) If medically necessary, treatment may include, contact lenses (for keratoconus, aphakia, high magnification difference between lenses), when requested in writing and prior authorized by Medicaid. (2) Orthoptics (eye exercises) must be prior authorized by Medicaid. Full inform…

(1) Services That May be Provided Other Than Correction of Refractive Error. (a) In the conduct of an optometric eye examination, if the optometrist suspects or detects abnormalities or irregularities requiring medical treatment the case will be referred to an appropriate doctor …

(1) Authorization (a) Recipients under 21 years of age are authorized two pair of glasses each year if indicated by an examination; a prior authorization will be required for subsequent pairs requested in a calendar year. Recipients 21 years of age and older are authorized one pa…

(1) All claims for payment of services rendered, filed by ophthalmologists, optometrists, and opticians are to be billed on appropriate form provided by the fiscal agent. (2) Claims are to be forwarded directly to the Medicaid fiscal agent for payment within one year of the date …

(REPEALED) Notes Ala. Admin. Code r. 560-X-17-.06 Rule effective October 1, 1982. Repealed: Filed January 17, 2012; effective February 21, 2012. Author: Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§ 401 ,et seq.

(1) Eye Care for Patients Eligible for Both Medicare and Medicaid. See the Medicaid Provider Manual for instructions in filing claims when the Medicaid patient is entitled to benefits covered by Medicare. (2) If eyeglasses are prescribed under conditions not covered by Medicare, …

Under the provisions of federal and state law. Medicaid must establish a mechanism to ensure that all care is of good quality and that the service(s) for which billing was made, conforms to that which was done. See Rule 560-X-2-.01(1) for criteria. Notes Ala. Admin. Code r. 560-X…

(1) Ophthalmologists and optometrists are required to collect and it is the Medicaid recipient's responsibility to pay the designated co-payment amount for each service rendered. This requirement includes patients with Medicare. (2) Exceptions to the copayment requirement are lis…

(1) The Title XIX (Medicaid) Plan for Alabama provides for transportation of eligible recipients to and from sources of medical care. Service will be provided either as a benefit or as an administrative expense through methods ranging from voluntary no-cost to paid ambulance tran…

(1) Recipient - An individual determined to be eligible for Medicaid under the state plan. (2) Ambulance. (a) Vehicle specifically designed and equipped for transporting the wounded, injured, ill, or sick. Medicaid recognizes three levels of ambulance services: Basic Life Support…

(1) All non-emergency ambulance service rendered to eligible Alabama Medicaid recipients 100 miles or more one way where medical care is received), requires prior authorization. (2) All requests for prior authorization by the attending physicians or their representatives will be …

(1) All transportation must be medically necessary and reasonable. Documentation must state the condition(s) that show necessity of ambulance service, (and indicate why patient could not be transported by another mode of transportation). (2) No payment may be made for ambulance s…

(1) All in-state and borderline out-of-state providers (within a 30-mile radius of the state line), in compliance with Rule No. 560-X-18-.02(2)(b) above, will be afforded an opportunity to sign an ambulance service contract with Alabama Medicaid Agency, to participate in the prog…

(1) The transportation provider is responsible for completion of the HCFA 1500 claim form. All claims submitted will be required to include the diagnosis code, modifiers, and indicators as appropriate. (2) Payment for ambulance services shall be based on the lesser of the submitt…

Claims for payment (appropriate forms provided by fiscal agent for Medicaid) from provider of service shall be submitted to fiscal agent for Medicaid within one year of the date of service. Authors: Charles A. Reasner, James V. Harris, R. Dale Boyles. Notes Ala. Admin. Code r. 56…

(1) Please refer to Chapter No. 560-X-20, Third Party, for information concerning filing insurance and release of information pertaining to recipients' changes. R. Dale Boyles Notes Ala. Admin. Code r. 560-X-18-.08 Rule effective October 1, 1982. Effective date of this amendment …

(1) An individual who is either sixty-five (65) years of age or older, who is under sixty-five (65) years of age, and who has been receiving green Social Security disability checks for twenty-four (24) consecutive months, who presents a current white Medicaid Eligibility Card wit…

Alabama Medicaid Agency and the Department of Human Resources (county level) shall work for procurement of additional volunteer transportation support from volunteer groups and nonprofit organizations. R. Dale Boyles Notes Ala. Admin. Code r. 560-X-18-.10 Rule effective October 1…

(1) All written or verbal communications pertaining to Alabama Medicaid recipients from out-of-state physicians or providers of ambulance transportation, will be referred to Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama 36104. (2) Appropriate billing forms will …