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The purpose of this memorandum is to inform providers about changes to Virginia Medicaid’s Fee-for Service Preferred Drug List (PDL) Program that will be effective on January 1, 2017 and new drug service authorization (SA) requirements approved by DMAS’ DUR Board. 

DMAS Drug Utilization Review Board Activities  

The DMAS Drug Utilization Review Board (DUR Board) met on November 10, 2016 and recommended that DMAS require prescribing providers to submit a Service Authorization (SA) for Venclexta™ (venetoclax) based on FDA approved labeling.  

Preferred Drug List (PDL) Updates – Effective January 1, 2017  

The PDL is a list of preferred drugs, by select therapeutic class, for which the Medicaid Fee-forService program allows payment without requiring service authorization (SA).  In designated classes, drug products classified as non-preferred will be subject to SA.  In some instances, other additional clinical criteria may apply to a respective drug class which could result in the need for a 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 applies to the Medicaid, FAMIS, and FAMIS Plus Fee-for-Service populations.  The Virginia Medicaid PDL does not apply to members enrolled in a Managed Care Organization (MCO). 

On October 20, 2016, the DMAS Pharmacy and Therapeutics (P&T) Committee conducted its annual review of the PDL Phase I drug classes and evaluated several new classes for addition to the PDL.

Of particular note, the P&T Committee approved criteria changes for the Hepatitis C Drug Class for the Medicaid Fee-for-Service program effective on January 1, 2017. The Committee eliminated the fibrosis scoring (Metavir) requirement as a part of the approval process and requires the prescriber to provide documentation of a Hepatitis C Patient Agreement (see attached sample Patient Agreement).  These changes will also be implemented by the Medicaid health plans in the Medallion 3.0 Managed Care program effective on January 1, 2017. 

The Committee approved the following changes and additions to Virginia Medicaid’s PDL:

The P&T Committee approved new or revised clinical edits for several drug classes or drugs on the PDL. Clinical edit criteria for all drugs and drugs classes are detailed on the PDL.  This list can be accessed at www.virginiamedicaidpharmacyservices.com/. 

The P&T Committee also approved clinical edits for the following drugs: 

• Aptensio® XR (stimulants)  
• Naplazid® (atypical antipsychotic)  
• Repatha™  (lipotropics)  
• Sernivo (topical steroids)       
• Taltz (cytokine and CAM antagonists)  
• Vopac MDS (topical NSAIDs) 
• Xrylis Kit (topical NSAIDs)  
• Zinbryta (multiple sclerosis)  

Virginia’s PDL can be found at http://www.dmas.virginia.gov/Content_pgs/pharm-pdl.aspx or https://www.virginiamedicaidpharmacyservices.com/.  In addition a copy of the PDL can be obtained by contacting the Magellan Clinical Call Center at 1-800-932-6648. Additional information and Provider Manual updates will be posted as necessary. Comments and questions regarding this program may be emailed to pdlinput@dmas.virginia.gov.

PDL and DUR Service Authorization (SA) Process  

A message indicating that a drug requires a SA will be returned at the point of sale (POS) when a prescription for a non-preferred drug is entered at point-of-sale (POS).  Pharmacists should contact the member’s prescribing provider to request that they initiate the SA process.  Prescribers can request a  SA  by letter, faxing to 1-800-932-6651, contacting the Magellan Clinical Call Center at 1-800-9326648 (available 24 hours a day, seven days a week), or by using the web-based service authorization process (Web SA).  Faxed and mailed SA requests will receive a response within 24 hours of receipt.  SA requests can be mailed to: 

Magellan Medicaid Administration 
ATTN:  MAP Department/ VA Medicaid  
11013 W. Broad Street, Suite 500  
Glen Allen, Virginia  23060

Service authorizations forms are available online at www.virginiamedicaidpharmacyservices.com.  The PDL criteria for SA purposes are also available on the same website. 

PDL 72-Hour-Supply Processing Policy and Dispensing Fee Process 

The PDL program provides a process where the pharmacist may dispense a 72-hour supply of a nonpreferred, prescribed medication if the prescriber is not available to consult with the pharmacist (afterhours, weekends, or holidays), AND the pharmacist, in his/her professional judgment, consistent with current standards of practice, feels that the patient’s health would be compromised without the benefit of the drug.  A phone call by the pharmacy provider to Magellan Medicaid Administration at 1-800932-6648 (available 24 hours a day, seven days a week) is required for processing a 72-hour supply. The member will be charged a co-payment applicable for this 72-hour supply (partial fill).  However, a co-payment will not be charged for the completion fill.  The prescription must be processed as a “partial” fill and then a “completion” fill.  For unit-of-use drugs (i.e., inhalers, drops, etc.), the entire unit should be dispensed and appropriate action taken to prevent similar situations in the future.

Pharmacy providers are entitled to an additional $3.75 dispensing fee when filling the completion of a 72-hour-supply prescription for a non-preferred drug.  To receive the additional dispensing fee, the pharmacist must submit the 72-hour supply as a partial fill and, when submitting the claim for the completion fill, enter “03” in the “Level of Service” (data element 418-DI) field.  The additional dispensing fee is only available (one time per prescription) to the pharmacist after dispensing the completion fill of a non-preferred drug when a partial (72-hour supply) prescription was previously filled.

DMAS Contact Information for Participating Pharmacies:

COMMONWEALTH COORDINATED CARE 

Commonwealth Coordinated Care (CCC) is a new initiative to coordinate care for individuals who are currently served by both Medicare and Medicaid and meet certain eligibility requirements.  Please visit the website at http://www.dmas.virginia.gov/Content_pgs/altc-home.aspx to learn more.

MANAGED CARE ORGANIZATIONS 

Many Medicaid recipients are enrolled with one of the Department’s contracted Managed Care Organizations (MCO).  In order to be reimbursed for services provided to an MCO enrolled individual, providers must follow their respective contract with the MCO.  The MCO may utilize different prior authorization, billing, and reimbursement guidelines than those described for Medicaid fee-for-service individuals.  For more information, please contact the MCO directly.  Additional information about the Medicaid MCO program can be found at http://www.dmas.virginia.gov/Content_pgs/mc-home.aspx.

VIRGINIA MEDICAID WEB PORTAL 

DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, payment status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov.  If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 1866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KEPRO’s Provider Portal at http://dmas.kepro.com. 

“HELPLINE”

The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays.  The “HELPLINE” numbers are: 
 
    1-804-786-6273      Richmond area and out-of-state long distance 
    1-800-552-8627      All other areas (in-state, toll-free long distance) 
 
Please remember that the “HELPLINE” is for provider use only.  Please have your Medicaid Provider Identification Number available when you call.  

Hepatitis C Therapy Patient Treatment Agreement 
Virginia Medicaid 

Prescriber Instructions: Please submit the completed agreement with the initial prior authorization requests.

Patient Instructions:  By reading and signing this agreement, I acknowledge that I have been informed about the requirements of the treatment program and understand what is expected of me.  I can refuse to sign this agreement, but treatment will not be started until and unless I sign this agreement. 

I have read the above statements and understand the agreement. 

Patient Signature: _______________________________________                 Date: _______________________

Physician Signature: _____________________________________                 Date: _______________________