Drug Utilization Review (DUR) Meeting Decisions Effective October 1, 2025

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Bulletin

September 26, 2025, 10:43AM

To:

All Providers 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 bulletin is to notify providers about routine changes to new drug service authorization (SA) requirements for drugs reviewed clinically and through fiscal analysis by the Drug Utilization Review (DUR) Board in June 2025.

The Drug Utilization Review Board is authorized by 12VAC30-130-340. The meetings of this committee is open to the public and is posted on the Virginia Town Hall meetings page.

June 2025 DUR Board Summary

Reviewed 8 T-Cell Therapy Drugs and approved their service authorization criteria

Abecma®, Aucatzyl®, Breyanzi®, Carvykti®, Kymriah®, Tecartus®, Tecelra® and Yescarta®

Reviewed 4 pipeline drugs

brensocatib oral, dordaviprone (ONC201) oral, rilzabrutinib oral and vatiquinone oral

Additionally, the Board reviewed the results of several utilization analyses:

The impact reports for 8 T-Cell Therapy Drugs (Abecma®, Aucatzyl®, Breyanzi®, Carvykti®, Kymriah®, Tecartus®, Tecelra® and Yescarta®)
Concurrent use of opioids and benzodiazepines
Concurrent use of opioids and antipsychotics
Overlaps in opioids, benzodiazepines, and antipsychotics
Naloxone and buprenorphine utilization for members on opioids
Glucagon-Like Peptide-1 Receptor Agonist (GLP-1 RA) Utilization
ProDUR reports
RetroDUR reports
Utilization analysis reports

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

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

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

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

Program of All-inclusive Care (virginia.gov)

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