Alabama Medicaid
Favorable for Coverage: Pharmacy Benefit (OTC)
Gelmix and Purathick are favorable for coverage as over-the-counter (OTC) products with a prescription under the pharmacy benefit.
Requirements
-Prescription required
-Prior Authorization required (must include quantity, day supply, diagnosis, and applicable ICD-10 codes; refer to the resources below for full PA requirements)
Product NDC Codes in AL
-Gelmix Infant Thickener (Sticks): 55764-0007-11
-Purathick Natural Thickener (Sticks): 55764-0007-14
Resources / Links
Miscellaneous Prior Authorization Form
NDC Lookup Tool