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The purpose of this bulletin is to notify providers and Managed Care Organizations about: (1) updates to the service authorization (SA) requirements for the Virginia Medicaid Physician Administered Drug (PAD) Program ; (2) updates for drugs reviewed clinically by the Drug Utilization Review (DUR) Board on June 11, 2026; and (3) changes to the Virginia Medicaid fee-for-service Preferred Drug List (PDL) (also known as the Common Core Formulary (CCF)) for drugs reviewed by the Department’s Pharmacy and Therapeutics Committee on July 16, 2026.

The Drug Utilization Review Board is authorized by 12VAC30-130-340 and the Pharmacy and Therapeutics Committee is authorized by 12VAC30-130-1000. The meetings of these committees are open to the public. The agendas and resulting minutes are posted on the Virginia Regulatory Town Hall meetings page.

The PDL/CCF is a list of preferred drugs by select therapeutic class for which the Medicaid Fee-for-Service (FFS) program may allow payment without requiring a SA. The PDL/CCF program aims to provide clinically effective and safe drugs for members in a cost-effective manner. 

The PDL/CCF is applicable to the Medicaid fee-for-service populations, and non-dual-eligible members covered under the Managed Care Program. The Virginia Medicaid PDL/CCF does not apply to members enrolled in FAMIS or members with Medicare Part D Plans.

1. PAD Program Updates

For instructions on billing physician-administered drugs, please refer to Chapter IV of the Virginia Medicaid Pharmacy Manual. Drugs that cannot be self-administered should be billed as a medical benefit to Virginia Medicaid by the administering physician or provider.

Virginia DMAS has implemented a new service authorization (SA) program for fee-for-service physician-administered drugs billed to the medical benefit. Certain physician-administered drugs are subject to SA requirements, which can be found in Appendix B: Physician Administered Drug Criteria.

How to Submit a Service Authorization Request: SA requests for drugs billed to the medical benefit via buy-and-bill may be submitted by fax.

• Fax: 804-452-5450

• Phone: 804-786-8056

• Mail: Virginia Department of Medical Assistance Services 600 E. Broad Street Richmond, VA 23219

Submission Requirements:

• Please include ALL required information and drug-specific criteria. For a complete list of drug-specific criteria, please visit the Virginia Medicaid Pharmacy Services Authorizations portal.

• Please submit clinical notes and a clinical summary to support medical necessity.

• Note: Incomplete forms or missing documentation will delay the SA review process. Submission of documentation does NOT guarantee coverage by the Department of Medical Assistance Services.

Alternative Pharmacy Benefit: Certain physician-administered drugs may also be available through the pharmacy benefit. Please consult the Preferred Drug List (PDL) and the Drug Lookup Tool to determine pharmacy benefit coverage.

Assistance and Questions: For service authorization assistance or questions related to physician-administered drugs, please email PhysicianAdministeredDrugs@dmas.virginia.gov

2. June 2026 DUR Board Meeting Summary

New Clinical Service Authorizations – effective date July 23, 2026

3. PDL Updates from July 2026 Pharmacy and Therapeutics Committee Meeting

On October 1, 2026 the following changes and additions to the Preferred Drug List (PDL) will be effective:

Classes in red with an * designate Common Core Formulary “closed classes”

AG=Authorized generic

Biosim=Biosimilar Drug

Provider Manual Title: Pharmacy

Revision Date: 07/16/2026

SA criteria can be found on the updated Preferred Drugs List (PDL/Common Core Formulary) at: 

https://www.virginiamedicaidpharmacyservices.com/provider/preferred-drug-list. 

SA forms for specific drugs or drug classes can be found at: https://www.virginiamedicaidpharmacyservices.com/provider/authorizations

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions.  Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.