Virginia Medicaid Preferred Drug List / Common Core Formulary and New Drug Utilization Review Board Approved Drug Service Authorizations Effective July 1, 2024
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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 3/21/24, 6/27/24, and 7/23/24 and new drug service authorization (SA) requirements for drugs reviewed by the Drug Utilization Review Board in March and June of 2024.
The Pharmacy and Therapeutics Committee is authorized by 12VAC30-130-1000 and the Drug Utilization Review Board is authorized by 12VAC30-130-340. The meetings of these committees are open to the public and are posted on the Virginia Town Hall meetings page.
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.
Drug Utilization Review Board – March 2024 Summary
The Board reviewed 6 new medications – AugtyroTM, FruzzaqlaTM, IwilfinTM, OgsiveoTM, TruqapTM, and WainuaTM. Additionally, the board reviewed the results of several utilization analyses: the impact reports for 6 new DUR medications (AugtyroTM, FruzzaqlaTM, IwilfinTM, OgsiveoTM, TruqapTM, and WainuaTM); Hepatitis C Compliance; concurrent use of opioids and benzodiazepines; concurrent use of a opioids and antipsychotics; overlaps in oprioids, benzodiazepines and antipsychotics; antipsychotic medications in children; antidepressant medications in childrem; mood stabuilizer medications in children; overlaps in antipsychotics, antidepressants and mood stabilizers in children; proDUR reports and utilization analysis reports.
Drug Utilization Review Board – June 2024 Summary
The Board reviewed 10 gene therapy drugs - Casgevy™, Elevidys, Hemgenix®, Luxturna®, Lyfgenia™, Roctavian™, Skysona®, Vyjuvek®, Zolgensma® and Zynteglo™. Additionally, the Board reviewed the results of several utilization analyses: the impact reports for the 10 gene therapy drugs (Casgevy™, Elevidys, Hemgenix®, Luxturna®, Lyfgenia™, Roctavian™, Skysona®, Vyjuvek®, Zolgensma® and Zynteglo™); utilization of oral oncology – lung cancer and other neoplasm drugs; concurrent use of opioids and benzodiazepines; concurrent use of opioids and antipsychotics; overlaps in opioids, benzodiazepines and antipsychotics; and naloxone and buprenorphine utilization for members on opioids.
March 2024 P&T Meeting PDL/CCF Changes
Virginia Preferred Drug List Changes Effective July 1, 2024 | ||
Drug Class | Preferred | Non-Preferred (requires SA) |
Stimulants and related agents for Narcolepsy (existing closed class)
| Armodafinil tablet Modafanil tablet Sunosi tablet |
|
Multiple Sclerosis Agents (existing closed class) | Teriflunomide tablet | Aubagio tablet |
Antimigraine Agents, Other (existing closed class) | Qulipta |
|
Immunomodulators, Asthma (new closed class) | Fasenra pen/syringe Xolair pen/syringe/vial | Cinqair injection Nucala autoinjector/syringe/vial Tezspire pen/syringe |
Macrolides/ketolides | Erythromycin base tablet DR | Erythromycin base capsule DR |
Acne Agents, Topical | Clindamycin phosphate gel | Sulfacetamide sodium/sulfur cleanser Clindamycin/benzoyl peroxide with pump ZMA clear cleanser |
Opiate Dependence Treatments (existing closed class) | Brixadi injection weekly and monthly |
|
Classes in red designate Common Core Formulary “closed classes”
AG=Authorized generic
June 2024 P&T Meeting PDL/CCF Changes
Virginia Preferred Drug List Changes Effective October 1, 2024 | ||
Drug Class | Preferred | Non-Preferred (requires SA) |
Colony Stimulating Factors (new closed class) | Neupogen Syringe Neupogen Vial Fulphila syringe | Fylnetra syringe Granix syringe/vial Leukine injection Neulasta kit/syringe Nivestym syringe/vial Nyvepria syringe Releuko syringe/vial Rolvedon syringe Stimufed syringe Udenyca syringe/autoinjector/Onbody Zarxio syringe Ziextenzo syringe |
Glucagon Agents (existing closed class) | Zegalogue syringe/autoinjector | Glucagon syringe Glucagon emergency kit (amphastat and Fresenius) Gvoke pen/syringe/vial |
Growth Hormone (existing closed class) |
| Nutropin AQ pen |
Duchenne Muscular Dystrophy (new closed class) | Emflaza tablet/susp | Deflazacort tablet Agamree susp Exondys-51 injection Amondys-45 injection Vyondys-53 injection Viltepso injection |
GI Motility Chronic | Lubiprostone capsule (AG) | Amitiza capsule |
Hepatitis B Agents (new closed class) | Entecavir tablet Lamivudine HBV tablet | Adefovir dipivoxil Baraclude tablet/solution Epivir HBV solution Lamivudine HBV tablet (AG) Vemlidy |
HIV/AIDS | Darunavir tablet | Prezista tablet |
Stimulants and Related Agents (existing closed class) | Amphetamine salt combo ER capsule and AG Dextroamphetamine ER capsule
| Adderall XR capsule Vyvanse chewable |
Anticonvulsants (existing closed class)
| Carbamazepine XR | Valtoco nasal spray |
Hypoglycemics, SGLT2 (existing closed class) | Synjardy XR tablet | Invokana tablet Invokamet tablet |
Glucocorticoids, Inhaled (existing closed class) | Alvesco Asmanex HFA QVAR Redihaler | Fluticasone HFA (AG) Fluticasone diskus (AG) |
Cytokine and CAM Antagonists (existing closed class) |
| Simlandi injection Tyenne injection |
Classes in red designate Common Core Formulary “closed classes”
AG=Authorized generic
July 2024 P&T Meeting PDL/CCF Changes
Virginia Preferred Drug List Changes Effective August 1, 2024 | ||
Drug Class | Preferred | Non-Preferred (requires SA) |
Weight management agents (existing closed class)
|
| Saxenda injection Wegovy injection |
Classes in red designate Common Core Formulary “closed classes”
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
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 |
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. | |
Managed Care Programs Cardinal Care Managed Care 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. | |
Cardinal Care Managed Care | https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-… |
PACE | |
Acentra Health Behavioral Health Services
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Provider Enrollment | In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com |
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 |
Aetna Better Health of Virginia | https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878
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Anthem HealthKeepers Plus | 1-800-901-0020
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Molina Complete Care
| 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx
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Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers
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United Healthcare | 1-844-284-0149
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Dental Provider DentaQuest | 1-888-912-3456 |