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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 which encompasses approximately seventy (70) therapeutic categories. Non-preferred agents in these categories require prior authorization. A prior authorization form, specifically designed for the request of non-preferred drugs, can be found below.

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 PA for specific agents are located on this site beside the PA criteria. Both the criteria and the PA form can be opened by clicking on the drug name or form. A general prior authorization form (General Drug PA Form) can be used when a drug to be requested is neither in a category included in the Preferred Drug List nor has a specific authorization form. The forms found on this website 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 and the corresponding prior authorization forms are listed below.

  Prior Authorization Criteria   PA Criteria Form  PA Consent Form
         
  Non-Preferred Drugs   PDL PA Form  
  Afinitor   General Drug PA Form  
  Amitiza    Amitiza PA Form  
  Ampyra   General Drug PA Form    
  Antifungal Agents   Antifungal PA Form   
  Atypicals-Children under 6 years (effective 7/1/2011)    Atypicals Antipsychotics for Children PA Form   
  Carbaglu    General Drug PA Form    
  Chantix   General Drug PA Form    
  Complera   General Drug PA Form  
  COX-2 Inhibitors    COX-2 Inhibitors PA Form   
  Daliresp   Daliresp PA Form  
  Dalvance   General Drug PA Form   
  Diabetic Supplies Limits (Pharmacy)   Diabetic Supplies Limits Exceptions Form   
  Diclegis    General Drug PA Form    
  Dificid    General Drug PA Form    
  Duavee    General Drug PA Form   
  ExJade    General Drug PA Form    
  Ferriprox    General Drug PA Form    
  Fulyzaq    General Drug PA Form  
  Fuzeon    General Drug PA Form    
  Gattex   General Drug PA Form    
  Gralise    General Drug PA Form    
  Growth Hormone for Adults    General Drug PA Form    
  Growth Hormone for Children    Growth Hormone PA Form (members under 21)   
  Harvoni   Hep C Generic Form Patient Consent Form  
  Home Infusion Drugs and Supplies    Home Infusion  PA Form   
  Humira or Enbrel   General Drug PA Form    
  Incivek   Incivek/Victrelis PA Form
  Invokana   General Drug PA Form    
  Increlex   General Drug PA Form    
  Juxtapid   General Drug PA Form    
  Kalydeco   General Drug PA Form    
  Ketoconazole    General Drug PA Form    
  Kuvan   General Drug PA Form    
  Linzess   General Drug PA Form    
  Max PPI and H2RA Doses      
  Mozobil   General Drug PA Form  
  Nuvigil   Provigil, Nuvigil PA Form  
  Oforta   General Drug PA Form  
  Olysio   Hep C Generic Form Patient Consent Form
  Osphena   General Drug PA Form    
  Otezla   General Drug PA Form   
  Otic Edge Drops (effective 7/1/2011)   General Drug PA Form  
  Provigil   Provigil, Nuvigil PA Form  
  Qualaquin    General Drug PA Form   
  Rectiv   General Drug PA Form    
  Regranex   General Drug PA Form    
  Relistor   General Drug PA Form    
  Rilutek   General Drug PA Form    
  Risperdal Consta   General Drug PA Form   
  Sirturo   General Drug PA Form    
  Sovaldi   Hep C Generic Form Patient Consent Form
  Sprycel   General Drug PA Form  
  Suboxone Subutex   Suboxone Subutex PA Form  
  Synagis   Synagis PA Form  
  Thalidomide    General Drug PA Form    
  V-Go   General Drug PA Form    
  Victrelis   Incivek/Victrelis PA Form  
  Vivitrol    Vivitrol PA Form    
  Votrient   General Drug PA Form    
  Xanax XR    General Drug PA Form    
  Xeljanz General Drug PA Form    
  Xifaxan 550mg    General Drug PA Form    
  Xolair   Xolair PA Form   
  Xyrem   General Drug PA Form    
  Zyvox   General Drug PA Form    
       
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