Virginia Medicaid Preferred Drug List / Common Core Formulary Changes, and New Drug Utilization Review Board Approved Drug Service Authorizations
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The purpose of this bulletin is to notify providers about routine changes 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 September 22, 2022 and new drug service authorization (SA) requirements for drugs reviewed by the Drug Utilization Review Board on June 2, 2022 and September 8, 2022. Changes to the PDL/CCF are effective January 1, 2023.
The PDL/CCF is a list of preferred drugs, by select therapeutic class, for which the Medicaid 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 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.
Virginia’s PDL/CCF and updates to it can be found at https://www.virginiamedicaidpharmacyservices.com/provider/preferred-drug-list. In addition, a copy of the PDL/CCF can be obtained by contacting the Magellan Clinical Call Center at 1-800-932-6648.
Provider Manual updates will be posted detailing PDL/CCF changes effective January 1, 2023. See appendix D in the pharmacy provider manual at https://vamedicaid.dmas.virginia.gov/manuals/pharmacy. 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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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. |
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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 |
www.aetnabetterhealth.com/Virginia 1-855-270-2365 1-866-386-7882 (CCC+) |
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Anthem HealthKeepers Plus |
1-833-207-3120 1-833-235-2027 (CCC+) |
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Molina Complete Care
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1-800-424-4524 (CCC+) 1-800-424-4518 (M4) |
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Optima Family Care |
1-800-643-2273 1-844-374-9159 (CCC+) |
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United Healthcare |
1-844-284-0149 1-855-873-3493 (CCC+) |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |