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The purpose of this bulletin is to notify providers about routine changes to new drug service authorization (SA) requirements for drugs reviewed clinically and through fiscal analysis by the Drug Utilization Review (DUR) Board on January 15, 2025 and to the Virginia Medicaid fee-for-service Preferred Drug List (PDL) program (also known as the Common Core Formulary or CCF) for drugs reviewed by the Department’s Pharmacy and Therapeutics Committee on January 16, 2025. 

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 and are posted on the Virginia 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 its Members in a cost-effective manner. Your continued compliance with and support of this program and its policies are critical to its success. 

The PDL/CCF is applicable to the Medicaid and FAMIS Plus fee-for-service populations, and nondual 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.

Drug Utilization Review Board – January 2025 Summary

The December 12, 2024 DUR meeting was cancelled. On January 15, 2025 in an emergency abbreviated meeting, the Board reviewed and provided feedback on the criteria for the 10 cell gene therapies from the previous June 13, 2024 meeting.  These criteria are adopted by the Department.

Physician Administered Drugs (PADs) - Gene Therapies: 

• Inpatient

a) Casgevy™ (exagamglogene autotemcel)

b) Lyfgenia™ (lovotibeglogene autotemcel)

c) Skysona® (elivaldogene autotemcel)

d) Zynteglo™ (betibeglogene autotemcel)

• Outpatient

a) Elevidys (delandistrogene moxeparvovec)

b) Hemgenix® (etranacogene dezaparvovec)

c) Luxturna® (voretigene neparvovec-rzyl)

d) Roctavian™ (valoctocogene roxaparvovec)

e) Vyjuvek® (beremagene geperpavec)

f) Zolgensma® (onasemnogene abeparvovec-xioi)

 January 2025 P&T Meeting PDL/CCF Changes

Classes in red designate Common Core Formulary “closed classes” 

SA criteria can be found on the updated Preferred Drugs List (PDL/CCF) 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