Prescription Drug Plan

PHARMACY UPCOMING CHANGE NOTICE

5/1/2024

Beginning 07/01/2024, WVCHIP Pharmacy POS claims will be processed by West Virginia Medicaid's claims processor, Gainwell Technologies. WVCHIP Pharmacy claims with dates of service from now through 06/30/2024 will continue to be processed by ESI, WVCHIP's current Pharmacy Benefit Manager (PBM). Please use WV Medicaid's Bank Identification Number (BIN), 610164, and Processor Control Number, DRWVPROD for WVCHIP drug claims with dates of service of 07/01/2024 and after. NOTE: WVCHIP members will receive new member cards prior to 07/01/2024 with updated information removing ESI as the PBM. Member ID numbers are not changing.

For questions regarding processing of WVCHIP pharmacy claims as of 07/01/2024, please refer to Health PAS Online - WV Medicaid and WVCHIP's Provider and Member portals, located at this link: https//www.wvmmis.com/default.aspx

Further details, specifically regarding WVCHIP claims processing, including the above named BIN and PCN, is located in the current WV Medicaid Vendor Specification Document D.O. on the Pharmcy link on that page, under the "Reference Material": tab, here: https://wvmmis.com/Pharmacy/Forms/Allitems.aspx

WVU's Rational Drug Therapy Program (RDTP) will continue to manage Prior Authorizations (PA) and Edit Overrides (EO) for WVCHIP. RDTP's phone number is 1-800-847-3859, and the fax number is1-800-531-7787. If you have any general question regarding this update, please contact Gainwell Technologies' WV Medicaid and WVCHIP's Pharmacy Provider Help Desk at 1-888-483-0801. The help desk number for members is 1-888-483-0797.

Providers must be enrolled with WV Medicaid and CHIP to ensure that prescriptions are processed and paid. Failing to enroll as a prescribing provider could cause your patients' prescriptions to be denied at the pharmacy. If you are not already enrolled, please visit https://www.wvmmis.com and enroll online as a billing provider or as an "ORP Only Provider." The quickest enrollment option is the ORP-Only online application process. To prevent interruptions in member's access to needed prescription medications, prescribers must make sure they are enrolled with West Virginia Medicaid.

Current Pharmacy Benefit Manager: Express Scripts, Inc. (ESI)

WVCHIP provides its members with prescription drug benefits. Prescription drug benefits are currently administered by Express Scripts, Inc. (ESI). Enrolling a child in the Plan atutomatically enrolls them in the prescription drug plan.

New Preferred Drug List for WVCHIP Members

The West Virginia Children’s Health Insurance Program updates the Preferred Drug List (PDL), annually. Click here for the current WVCHIP Preferred Drug List.

Non-preferred drugs will not be covered. If a provider chooses to prescribe a drug not listed on the Preferred Drug List (PDL), it will be a 100% retail cost to the patient. Co-payments for drugs on the new PDL will remain the same. Questions concerning drugs covered by WVCHIP should be directed to Express Scripts at 1-855-230-7778.

Rational Drug Therapy Program Now Reviews Prior Authorization Drug Requests

Effective July 1, 2005, the West Virginia University School of Pharmacy's Rational Drug Therapy Program assumed review authority for all prior authorization requests for West Virginia Children's Health Insurance Program (WVCHIP).

Contact the West Virginia University School of Pharmacy, Rational Drug Therapy Program, for all prior authorization reviews, at 1-800-847-3859.

The process is typically resolved over the phone. If done by letter the process can take up to two business days.

The following link is for providers who want to print out the Prior Authorization Form to submit to the Rational Drug Therapy Program: Prior Approval Request Form.

Drugs Requiring Prior Authorization

Several classes of prescription drugs require prior authorization for coverage by WVCHIP. The prior authorization process will involve the child’s physician and pharmacist communicating with WVU’s School of Pharmacy, Rational Drug Therapy Program (RDTP), about the situation, since these prior approvals are given on a case-by-case basis. The child's doctor must call RDTP. If your medication is not approved for plan coverage, you will have to pay the full cost of the drug. WVCHIP will cover, and your pharmacist can dispense, up to a five-day supply of a medication requiring prior authorization for the applicable copayment. This policy applies when your doctor is either unavailable or temporarily unable to complete the prior authorization process promptly.

To download a printer friendly PDF version of the ADD Medication Prior Approval Request Form click here.

Prior Approval for Medicine for Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder

Prior Authorization Policy - Therapeutic Guidelines

ADHD medications need prior approval through the Rational Drug Therapy Program (RDTP). The goals of this therapeutic guideline policy is to promote overall disease management such that medication treatment is supported by adjunctive psychosocial programs, ample patient contact, and frequent follow-up visits throughout the course of therapy to address non-medication treatment alternatives, comorbid disorders, dosage titration, adverse effects, and drug diversion and misuse.

In order to simplify the process for the providers, we have revised an RDTP prior approval form and changed it to specifically address the ADHD/ADD prior approval process.

Prior Approval Request Form for Attention Deficit Disorder Medication

Please note: Members that are currently taking a drug that is used to treat, or in sensitive to, mental conditions, can continue to have their current prescriptions(s) covered even if their current medication is not on the WVCHIP PDL (Preferred Drug List) when it is in one of the following seven drug classes: Antipsychotics; Serotonin Selective Response Inhibitors (SSRI); Central Nervous System Stimulants; Anticonvulsants; Sedative Hypnotics; Aliphatic Phenothiazine's; and Attention Deficit Disorder drugs.

Members who are newly prescribed a drug used to treat, or is sensitive to, mental conditions in one of the seven drug classes named above will have prescriptions filled from the WVCHIP PDL, except in cases where there is a demonstrated neeed for exception due to medical necessity.

For the WVCHIP PDL, see WVCHIP website at chip.wv.gov.

Common Specialty Medications

All specialty medications require prior authorization. The process begins with a call to Express Scripts at 1-855-230-7778. ESI will review the drug for medical necessity, and if approved, will coordinate the purchase through an approved source. Specialty drugs have the following key characteristics:
Need frequent dosage adjustments
Cause more sever side effects than tradional drugs
Need special storage, handling and or administration
Have a narrow therapeutic range
Require a periodic laboratory or diagnostic testing..

Please refer to the list of the most "Common Specialty Medications" listed in the Summary Plan Description.

Frequently Asked Questions

Q. Who do I call about prescription drug coverage?

A. Contact Express Scripts at 1-855-230-7778 or visit them online at www.express-scripts.com. Click here for the current WVCHIP Preferred Drug List.

Q. Who do I call to preauthorize prescription drug coverage?

A. Contact WVU's Rational Drug Therapy Program at 1-800-847-3859.