Virginia Medicaid Preferred Drug List / Common Core Formulary Changes, 90 Day Supply List Changes, and Drug Utilization Review Board Approved Drug Service Authorizations
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The purpose of this memorandum is to notify providers about updates to the Virginia Medicaid’s fee-for-service (FFS) Preferred Drug List (PDL) Program, 90 day supply list, 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, or Common Core Formulary (CCF), is a list of preferred drugs, by select therapeutic class, for which the Medicaid fee-for-service program allows payment without requiring an 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/CCF is effective for the Medicaid, non-dual eligible members enrolled in fee-for-service or managed care programs. The PDL/CCF does not apply to members enrolled in FAMIS or members with Medicare Part D plans.
Virginia’s PDL/CCF and 90 day list and any updates may be found at https://www.virginiamedicaidpharmacyservices.com/provider/ under PDL/Common Core Formulary and Documents, respectively. In addition, copies of the PDL and 90 day supply list 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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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 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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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 |
1-800-881-2166 www.optimahealth.com/medicaid |
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United Healthcare |
and www.myuhc.com/communityplan 1-844-752-9434, TTY 711 |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |