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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 (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. 

  Prior Authorization Criteria   PA Criteria Form  PA Consent Form
  Non-Preferred Drugs   PDL PA Form  
  Aubagio   Aubagio PA Form    
  Afinitor   General Drug PA Form  
  Amitiza   Amitiza PA Form III v2.pdf  
  Ampyra   General Drug PA Form    
  Anoro Ellipta   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  
  Diabetic Supplies Limits (Pharmacy)   Diabetic Supplies Limits Exceptions Form   
  Diclegis    General Drug PA Form    
  Dificid    General Drug PA Form    
  Duavee    General Drug PA Form   
  Epaned   General Drug PA Form    
  Esbriet   Esbriet PA Form      
  Evzio    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    
  Grastek, Oralair, Ragwitek   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 XIII.pdf Patient Consent Form  
  Harvoni Continuation   Hep C Continuation Form      
  Home Infusion Drugs and Supplies    Home Infusion  PA Form   
  Horizant   General Drug PA Form    
  Humira or Enbrel   General Drug PA Form    
  HyQvia   General Drug PA Form     
  Increlex   General Drug PA Form
  Invokana   General Drug PA Form    
  Jublia   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    
  Mozobil   General Drug PA Form  
  Nuvigil   Provigil, Nuvigil PA Form  
  Oforta   General Drug PA Form  
  Olysio   Hep C Generic Form XIII.pdf Patient Consent Form
  Olysio Continuation   Hep C Continuation Form    
  Osphena   General Drug PA Form    
  Otezla 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    
  Restasis   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 XIII.pdf Patient Consent Form
  Sovaldi Continuation   Hep C Continuation 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    
  Viekira Pak   Hep C Generic Form XIII.pdf    
  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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