Prior Authorization 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.

 
Healthcare Common Procedure Coding System (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 Acentra Health (formerly 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.
 
Point of Sale/PDL Criteria
West Virginia Medicaid has established a Preferred Drug List (PDL) which encompasses approximately 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 West Virginia 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 Prior Authorization 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 Prior Authorization Forms page.  Non-preferred PDL drugs that do not have a specific Prior Authorization form may be requested through the use of the “Non-Preferred Drug Prior Authorization Form”. When requesting a preferred drug that requires a prior authorization, 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 Prior Authorizaiton Form”.  The 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
Chronic Opioid PA Form
Adbry
Afinitor
Albenza and Emverm
Amondys 45
Antifungal Agents
Atypical Antipsychotic Ag​ents for Children up to age 18
Austedo 
Be​lbuca
Benly​​sta
Cabenuva
Cam​zyos
Carbaglu
CGRP Recep​tor Antagonists
Cibi​nqo
Continuous Gluco​se M​onitors
Corlanor
Cresemba
Cuvposa
Cytokine & ​CAM Antagonists
Diclegis 
​​Dif​icid
Dojolvi
Droxidopa
Duavee
Dupi​xent
Emflaza
Enspryng
Esbriet
Evr​y​​sdi
ExJade

Fasenra
Ferriprox
Fin​tepla
Fuzeon
Gattex
Growth Hormone for Adults
Growth Hormone for Children
Hepatitis​ ​C ​PA Criteria
Hereditary Angioedema Agents
Hetli​oz
Home Infusion Drugs and Supplies
Horizant
HP Acthar
HyQvia
Increlex
Ingrezza
Jublia
Juxtapid
Kalydeco
Kerendia
Ketoconazole
Korlym
Kuvan
Kynamro
Leqv​io
Lucemyra
Lupkynis
Max PPI an H2RA
Mozobil
Myalept
Myfe​mbr​ee
Mytesi
Natpara
Nexletol and Nexlizet
Non-Sedating Antihistamines
Narcoleptic Agents
Nucala
N​uzyra
OFEV
Oforta
Om​nipod
Opzelu​ra
Oril​issa
Oralair
Oriahnn
Orka​mbi
Osphena
Oxlumo
Palforzia
Palynziq
PCSK9 In​hibitor
Qelbre​e
Rectiv


Riluzole
Rinvoq
Risperdal Consta
Sirturo 
Spravato
Subox​one Policy
Symdeko
S​ynagis
Testos​te​rone
Tez​sp​ire
Thalomid
Tobacco ​Ce​s​sation Policy
Tri​kafta
V-Go
Viberzi and Lotronex
Verquvo
Vo​wst
Vox​zogo
Xanax XR 
Xenazine
Xhance
Xifaxan
X​ol​a​ir
Xyrem an​d Xywav
Zurampic
Zyvox
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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