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June 10, 2022, 04:23 EDT

Chapter : Appendix D: Preferred Drug List / Common Core Formulary Changes, and Drug Utilization Review Board Service Authorization Changes

Updated: 6/10/2022

Preferred Drug List / Common Core Formulary Changes, 90 DAY SUPPLY LIST CHANGES, and Drug Utilization Review Board Service Authorization Changes

The following updates were recently recommended and approved by the Drug Utilization Review Board and the DMAS Pharmacy and Therapeutics (P&T) Committee.  These changes, along with a complete listing of preferred drugs and service authorization requirements, are posted on the Virginia Medicaid Pharmacy Services Portal at: https://www.virginiamedicaidpharmacyservices.com/provider

Effective immediately, the following drugs require a service authorization (SA). SA forms can be found at: https://www.virginiamedicaidpharmacyservices.com/provider/authorizations

  • BesremiR (ropeginterferon alfa-2b-njft)
  • LivtencityTM (maribavir)
  • ScemblixR (asciminib)
  • TavneosTM (avacopan)
  • VoxzogoTM (vosoritide)
  • ExkivityTM (mobocertinib)
  • KerendiaR (finerenone)
  • WeliregTM (belzutifan
  • FotivdaR (tivozanib)
  • LumakrasTM (sotorasib)
  • MyfembreeR (relugolix, estradiol, and norethindrone acetate)
  • TruseltiqTM (infigratinib)
  • WegovyTM (semaglutide)

The DMAS P&T Committee conducted its annual review of the following PDL Phase II drug classes and reviewed new drugs in PDL Phase I on March 17, 2022. On July 1, 2022, the following changes, and additions to the Preferred Drug List (PDL) will be effective. 

 

Virginia Preferred Drug List Changes Effective July 1, 2022

Drug Class

Preferred

Non-Preferred

 (requires SA)

Antivirals, Topical

-acyclovir ointment (topical)

-docosanol OTC (topical)

-Abreva OTC (topical)

-Zovirax (topical)

Antimigraine, Other

(NEW CLOSED CLASS)

-Nurtec ODT

-Ubrelvy

Antipsychotics

quetiapine ER

-quetiapine ER (AG)

COPD Agents

-Spiriva Respimat

NA

Cytokine and CAM Antagonists

-Inflectra (IV)

-Renflexis (IV)

Hypoglycemics, Insulins

-insulin aspart cartridge/pen/vial

-insulin aspart/insulin aspart protamine insulin pen/vial

-insulin lispro Junior pen

-insulin lispro pen

-insulin lispro protamine mix pen

-Novolog Mix Pen/Vial

Hypoglycemics, Incretin Mimetics

 

-Glyxambi

Multiple Sclerosis

(NEW CLOSED CLASS)

 

-dimethyl fumarate DR

-dimethyl fumarate DR starter pack

-Tecfidera

-Tecfidera Starter Pack

Progestational agents (NEW CLOSED CLASS)

NA

NA

Stimulants

-dexmethylphenidate

-Focalin

Classes in red designate Common Core Formulary “closed classes”

NEW 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

 

 

Virginia 90 day list changes Effective July 1, 2022

Drug Class

Added

Removed

COPD Agents

-Spiriva Respimat

NA

Hypoglycemics, Insulins

-insulin aspart cartridge/pen/vial

-insulin aspart/insulin aspart protamine insulin pen/vial

-insulin lispro junior pen

-insulin lispro pen

-insulin lispro protamine mix pen

-Novolog Mix Pen/Vial