PA Criteria

 It is the goal of the West Virginia Medicaid Program to improve the quality of care and health outcomes for West Virginia Medicaid members by assuring that the medications prescribed for them are appropriate, medically necessary, and not likely to result in adverse medical effects. The Drug Utilization Review Board and Pharmaceutical and Therapeutics Committee work with the Pharmacy Program to promote utilization of agents that are both therapeutically effective and cost efficient through educational programs and establishment of prior authorization criteria for selected agents. Prior authorization criteria are established based on input from current research and literature, evidence based guidelines, participating prescribers and other experts. The Drug Utilization Review Board is responsible for making final recommendations for all prior authorization criteria for the Medicaid Pharmacy Program.

West Virginia Medicaid has established a Preferred Drug List (PDL) which encompasses approximately seventy (70) therapeutic categories. Non-preferred agents in these categories require prior authorization.  Drugs or drug classes which are found to be over utilized, abused, have significant safety concerns, or are costly are also candidates for prior authorization. All injectable drugs require prior authorization. More complete information regarding the pharmacy program policies can be found in Chapter 518, Pharmacy Services of the WV Medicaid Manual.

West Virginia Medicaid contracts with the West Virginia University School of Pharmacy Rational Drug Therapy Program (RDTP) for prior authorization services. Prior authorization requests can be made by printing, completing and faxing the appropriate PA form to (800) 531-7787. 

The forms for requesting prior authorizations for specific agents can be found within the respective criteria page below, but may also be found separately on the PA FORMS page.  Non-preferred PDL drugs that do not have a specific PA form may be requested through the use of the “Non-Preferred Drug PA Form”. When requesting a preferred drug that requires a PA, or whenever the drug being requested is neither on the PDL nor has a specific authorization form assigned to it, please use the “General Drug PA Form”.  RDTP staff pharmacists are available for assistance with prior authorization requests by calling (800) 847-3859.

Agents with prior authorization criteria are listed below.  For information on prior authorization criteria for drugs not listed below, please contact the Office of Pharmacy Services at (304) 558-1700.  Additional information may also be listed on the PDL.
​A-D E-J​ ​K​-Reo Rep-Z​
General Drug PA Form
​Afinitor​
​Albenza and Emverm
​​Amitiza
​Ampyra
​Anoro Ellipta
​Antifungal Agents​
Atypical Antipsychotic Agents for Children up to age 18
Aubagio
Austedo​
​Belbuca
​Carbaglu
Chantix
Cinryze
​Corlanor
​​COX-2 Inhibitors
Cresemba
Curvposa
Dailiresp​
Diabetic Supplies Limits (Pharmacy)
​Diclegis
​​Dificid
​Droxidopa
​​Duavee
Epaned
Esbriet
Eucrisa
ExJade
Ferriprox
Firazyr
Fuzeon
Gattex
Gralise
Grasteck
Growth Hormone for Adults
Growth Hormone for Children
Hepatitis C PA Criteria
Hetlioz
Home Infusion Drugs and Supplies
Horizant
HP Acthar
Humira and Enbrel
HyQvia
Increlex
Ingrezza
Invega Trinza
Jublia
Juxtapid
​Kalydeco
Ketoconazole
Korlym
Kuvan
Linzess
Makena
Max PPI an H2RA
Movantik
Mozobil
Myalept
Mytesi
Natpara
Nuvigil
Oforta
Opioids
Oralair
Orkambi
Osphena
Praluent
Provigil
Qualaquin
Ragwitek
Rectiv
Regranex
Relistor
Remicade
​Repatha
​Restasis
​​Rilutek  
Riluzole
Risperdal Consta
​​Sirturo 
Spinraza
​Sprycel
Suboxone
​​Synagis
Thalomid
​V-Go
Viberzi and Lotronex
Xanax XR 
Xenazine
​Xifaxan
Xolair
Zurampic
Xyrem
​Zyvox
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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