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.
 
HCPCS Drugs Facility/Physician Reimbursement Criteria
Some medications/drugs/agents are only available via "Buy and Bill" using HCPCS drug codes. For these agents, West Virginia Medicaid contracts with KEPRO prior authorization services. Prior authorizations must be requested through KEPRO, by calling (304) 343-9663, faxing (866) 209-9632 or emailing WVMedicaidServices@KEPRO.com.  Agents with prior authorization criteria are listed below. A full listing of medications/drugs/agents available via "Buy and Bill" HCPCS codes may be found on the Bureau for Medical Services (BMS) website under HCPCS/Drug Code List:  https://dhhr.wv.gov/bms/HCPCS/Pages/default.aspx.
 
Point of Sale/PDL Criteria
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-E F-L M -Reo Rep-Z
General Drug PA Form
Afinitor
Albenza and Emverm
Ampyra
Antifungal Agents
Atypical Antipsychotic Agents for Children up to age 18
Austedo
Belbuca
Carbaglu
CGRP Receptor Antagonists
Continuous Glucose Monitors
Corlanor
Cresemba
Cuvposa
Cytokine & CAM Antagonists
Diclegis 
​​Dificid
Droxidopa
Duavee
Dupixent
Epidiolex
Emflaza
Esbriet
ExJade
Exondys 51
Fasenra
Ferriprox
Firazyr
Fuzeon
Gattex
Gralise
Grastek
Growth Hormone for Adults
Growth Hormone for Children
Hepatitis C PA Criteria
Hereditary Angiotensin Agents
Hetlioz
Home Infusion Drugs and Supplies
Horizant
HP Acthar
HyQvia
Increlex
Ingrezza
Jublia
Juxtapid
Kalydeco
Ketoconazole
Korlym
Kuvan
Kynamro
Lucemyra
Makena
Max PPI an H2RA
Mozobil
Myalept
Mytesi
Natpara
Non-Sedating Antihistamines
Nuvigil
Nucala
OFEV
Oforta
Omnipod
Orilissa
Opioids
Oralair
Orkambi
Osphena
Palynziq
PCSK9 Inhibitor
Provigil
Qbrexza
Qualaquin
Ragwitek
Rectiv
Regranex
Remicade
Restasis
Rilutek  
Riluzole
Risperdal Consta
Sirturo 
Spravato
Sprycel 
Suboxone Policy
Symdeko
Synagis
Testosterone
Thalomid
Tobacco Cessation Policy
Trikafta
V-Go
Viberzi and Lotronex
Xanax XR 
Xenazine
Xhance
Xifaxan
Xolair
Xyrem
Zurampic
Zyvox
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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