Virginia Medicaid Preferred Drug List / Common Core Formulary Changes, and Drug Utilization Review Board Approved Drug Service Authorizations
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The purpose of this memorandum is to notify providers about the Virginia Medicaid’s fee-for-service (FFS) Preferred Drug List (PDL) Program and drug service authorization (SA) requirements for drugs reviewed by the Department’s Pharmacy and Therapeutics Committee and the Drug Utilization Review Board.
The PDL/Common Core Formulary is a list of preferred drugs, by select therapeutic class, for which the Medicaid fee-for-service program allows payment without requiring SA. The PDL program aims to provide clinically effective and safe drugs to its members in a cost-effective manner. Your continued compliance and support of this program is critical to its success.
The PDL/Common Core Formulary is effective for the Medicaid, FAMIS Plus fee-for-service populations and non-dual eligible members covered under the CCC Plus program and managed care members enrolled with Medallion 4.0. The Virginia Medicaid PDL does not apply to members enrolled in FAMIS or members with Medicare Part D plans.
Virginia’s PDL/Common Core Formulary and updates to it can be found at https://www.virginiamedicaidpharmacyservices.com/provider/preferred-drug-list. In addition, a copy of the PDL can be obtained by contacting the Magellan Clinical Call Center at 1-800-932-6648.
Provider Manual updates will be posted about PDL changes. Comments and questions regarding this program can be emailed to pdlinput@dmas.virginia.gov.
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PROVIDER CONTACT INFORMATION & RESOURCES |
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Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
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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 |
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KEPRO Service authorization information for fee-for-service members. |
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Managed Care Programs Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), 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. |
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Medallion 4.0 |
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CCC Plus |
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PACE |
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Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. |
www.MagellanHealth.com/Provider For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or call: 1-800-424-4046
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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 |
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Aetna Better Health of Virginia |
aetnabetterhealth.com/virginia 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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Magellan Complete Care of Virginia |
1-800-424-4518 (TTY 711) or 1-800-643-2273 |
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Optima Family Care |
1-800-881-2166 |
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United Healthcare |
Uhccommunityplan.com/VA and myuhc.com/communityplan
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Virginia Premier |
1-800-727-7536 (TTY: 711) |
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