Virginia Medicaid Preferred Drug List / Common Core Formulary and New Drug Utilization Board Approved Drug Service Authorizations Effective January 1, 2025
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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 by the Drug Utilization Review (DUR) Board on 9/12/24 and to 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 10/8/24.
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 to 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, 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 – September 2024 Summary
The Board reviewed 7 new medications - Alvaiz™, Fabhalta®, Filsuvez®, Rezdiffra™, Rivfloza™, Voydeya™ and Zilbrysq®. Information regarding the drugs and Service Authorization (SA) criteria were discussed. Additionally, the Board reviewed the results of several utilization analyses: the impact reports for the 7 new DUR medications (Alvaiz™, Fabhalta®, Filsuvez®, Rezdiffra™, Rivfloza™, Voydeya™ and Zilbrysq®); antipsychotic medications in children; antidepressant medications in children; mood stabilizer medications in children; overlaps in antipsychotics, antidepressants and mood stabilizers in children; Synagis utilization; ProDUR reports; RetroDUR reports and utilization analysis reports.
October 2024 P&T Meeting PDL/CCF Changes
Virginia Preferred Drug List Changes Effective January 1, 2025 | ||
Drug Class | Preferred | Non-Preferred (requires SA) |
Laxatives and Cathartics (new closed class) | Lactulose solution PEG 3350/Electrolytes solution for reconstitution PEG 3350/Flavor packs solution for reconstitution PEG 3350/Electrolytes powder pack (AG) | Moviprep powder pack Golytely solution for reconstitution Nulytely with flavor packs solution for reconstitution Suprep solution for reconstitution Clenpiq Sodium, potassium mag sulfates, solution for reconstitution Suflave powder Sutab Plenvu PEG 3350/electrolytes powder pack Kristalose packet |
Anticonvulsants (existing closed class) | Sezaby Depakote Sprinkle | Divalproex sprinkle Tiagabine Lamotrigine ODT |
Immunomodulators, Atopic Dermatitis (existing closed class) | Adbry autoinjector Pimecrolimus (AG) |
|
Sickle cell Anemia (existing closed class) | Siklos |
|
Hypoglycemics, insulin and related agents | Toujeo solostar pen | Insulin glargine vial and pen Novolog pen, cartridge and vial |
Bladder relaxants | Myrbetriq Fesoterodine ER | Toviaz |
Hemophilia treatments (existing closed class) | Balfaxar |
|
Ophthalmics, anti-inflammatories |
| Ketorolac LS |
Movement Disorders (existing closed class)
|
| Xenazine |
COPD (existing closed class) |
| Ohtuvraye |
Pulmonary Arterial Hypertension |
| Winrevair |
Classes in red designate Common Core Formulary “closed classes”
AG=Authorized generic
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.
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | 1-800-884-9730 or 1-800-772-9996 |
Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. | |
Managed Care Programs Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. | |
Cardinal Care Managed Care | https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-… |
PACE | |
Provider Enrollment | In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com |
Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. | 1-804-786-6273 1-800-552-8627 |
Aetna Better Health of Virginia | https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878
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Anthem HealthKeepers Plus | 1-800-901-0020
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Molina Complete Care
| 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx
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Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers
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United Healthcare | 1-844-284-0149
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Dental Provider DentaQuest | 1-888-912-3456 |
Fee-for-Service (POS) Prime Therapeutics
| https://www.virginiamedicaidpharmacyservices.com/ 1-800-424-4046 |
Acentra Health Behavioral Health and Medical Service Authorizations | https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 |