Updates to the Pharmacy Provider Manual Appendix D and E

Memo

June 30, 2023, 10:36AM

To:

All prescribing Providers, Pharmacists and Managed Care Organizations Participating in the Virginia Medical Assistance Program

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this memorandum is to notify providers of the revisions to Appendix D and Appendix E in the pharmacy manual.

Appendix D includes information regarding updates to the Virginia Medicaid’s Preferred Drug List (PDL) or Common Core Formulary and fee-for-service (FFS) drug service authorization requirements for drugs reviewed by the Department’s Pharmacy and Therapeutics Committee and the Drug Utilization Review (DUR) Board. This revision includes changes to the PDL/Common Core Formulary and 90-day list effective July 1, 2023, and new drugs reviewed by the DUR Board since the last manual update on December 5, 2022.

Appendix E includes all medications which may be dispensed as a 90-day supply, effective July 1, 2023.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

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

Acentra Health

Service authorization information for fee-for-service members.

https://dmas.kepro.com/

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.

https://www.dmas.virginia.gov/appeals/

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.

Medallion 4.0

http://www.dmas.virginia.gov/#/med4

CCC Plus

http://www.dmas.virginia.gov/#/cccplus

PACE

http://www.dmas.virginia.gov/#/longtermprograms

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

www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or

Call: 1-800-424-4046

Provider Enrollment