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 of 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.
Forms for requesting prior authorizations for specific agents are located on this site within the actual PA criteria. A general prior authorization form can be used when a drug to be requested is neither on the PDL nor has a specific authorization form. These forms can be completed, printed and faxed to the Rational Drug Therapy Program.
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 faxing the appropriate PA form to (800) 531-7787.
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.