Virginia Medicaid Drug Utilization Review Board Approved Updates and Preferred Drug List Effective July 1, 2026

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Bulletin

May 5, 2026, 1:33PM

To:

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

From:

Steve Ford, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to notify providers and Managed Care Organizations about routine changes to drug service authorization (SA) requirement updates for drugs reviewed clinically by the Drug Utilization Review (DUR) Board on March 12, 2026 and to the Virginia Medicaid fee-for-service Preferred Drug List (PDL) (also known as the Common Core Formulary or CCF) for drugs reviewed by the Department’s Pharmacy and Therapeutics Committee on April 16, 2026.

The Drug Utilization Review Board is authorized by 12VAC30-130-340and the Pharmacy and Therapeutics Committee is authorized by 12VAC30-130-1000. The meetings of these committees are open to the public. The agendas and resulting minutes are posted on the Virginia Regulatory Town Hall meetings page.

The PDL/CCF is a list of preferred drugs by select therapeutic class for which the Medicaid Fee-for-Service (FFS) program may allow payment without requiring a SA. The PDL/CCF program aims to provide clinically effective and safe drugs for 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 and FAMIS Plus fee-for-service populations, and nondual 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.

March 2026 DUR Board Meeting Summary

Reviewed 14 Traditional DUR Drugs

Aqvesme™, Ensacove™, Hyrnuo®, Inluriyo™, Isturisa®, Jascayd®, Komzifti™, Lynkuet®, Palsonify™, Pyrukynd®, Recorlev®, Rhapsido®, Vanrafia™ and Voyxact®

Approved 12 Traditional DUR Drugs Service Authorization Criteria

Ensacove™, Hyrnuo®, Inluriyo™, Isturisa®, Jascayd®, Komzifti™, Palsonify™, Pyrukynd®, Recorlev®, Rhapsido®, Vanrafia™ and Voyxact®

Reviewed 2 Physician Administered Drugs (PADs) and approved their Service Authorization Criteria

Kebilidi™ and Zevaskyn™

PDL Updates from April 2026 Pharmacy and Therapeutics Committee Meeting

On July 1, 2026 the following changes and additions to the Preferred Drug List (PDL) will be effective:

Drug Class

Preferred

Non-Preferred

*Hepatitis C Agents

Sofosbuvir/velpatisvir oral AG

*Immunomodulators, Atopic Dermatitis

Ebglyss syringe and pen

Vtama topical

*Immunomodulators, Asthma

Tezspire syringe and pen

*Anticoagulants

Dabigatran oral

Pradaxa oral

*Glucagon Agents

Gvoke vial, syringe and pen injection

*Hypoglycemics, Incretin Mimetics/Enhancers

Trijardy XR oral

Glyxambi oral

Angiotensin Modulators

Sacubitril/valsartan oral

Entresto oral

Platelet Aggregation Inhibitors

Ticagrelor oral

Brilinta oral

Antibiotics, Vaginal

Nuvessa

Bone Resorption Suppression and Related Agents

Enoby injection (biosim)

Xtrenbo injection (biosim)

Bildyos injection (biosim)

Bilprevda injection (biosim)

Macrolides/Ketolides

E.E.S 200 Oral Suspension

Classes in red with * designate Common Core Formulary “closed classes”

AG=Authorized generic

Biosim=Biosimilar drug

SA criteria can be found on the updated Preferred Drugs List at:

https://www.virginiamedicaidpharmacyservices.com/provider/preferred-drug-list.

SA forms for specific drugs or drug classes can be found at: https://www.virginiamedicaidpharmacyservices.com/provider/authorizations

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