Virginia Medicaid implemented a Common Core Formulary – a “core” list of covered drugs for all Medicaid members enrolled with the Fee-for-Service, Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) Managed Care programs across the Commonwealth – effective on December 1, 2018.
The Common Core Formulary includes all the “preferred” drugs on DMAS’ Preferred Drug List (PDL) in approximately 90 therapeutic drug classes. Medallion 4 and CCC Plus health plans are contractually required to cover all “preferred” drugs on Virginia Medicaid’s PDL/Common Core Formulary and cannot place additional restrictions (such as prior authorizations, step therapies, quantity limits, etc.) on the “preferred” drugs. The Medicaid managed care health plans may add drugs to therapeutic drugs classes on the DMAS PDL/Common Core Formulary but cannot remove drugs.
The Medicaid health plans will accept the DMAS/Magellan service authorization from this website for any of the preferred medications.
It is important to note that the DMAS PDL/Common Core Formulary does not apply to Medicaid members that receive Medicare benefits and full Medicaid benefits (dual eligibles). The drug benefits for dual eligibles members are defined by the member’s Medicare Part D plan.
The DMAS PDL is not a comprehensive formulary, so the health plans’ formularies will be more extensive. For therapeutic drug classes not included on the DMAS PDL (e.g., oral oncology drugs, HIV drugs, etc.), each health plan will publish a formulary with the plan’s covered drugs.
DMAS has established a mailbox for providers to send questions or concerns regarding Common Core Formulary drug coverage.
Issues related to drug coverage and/or denials for preferred drugs on the DMAS PDL should be sent to [email protected].