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Pharmacy Benefit Manager:  Gainwell Technologies' WV Medicaid and WVCHIP

WVCHIP provides its members with prescription drug benefits. Prescription drug benefits are currently administered by Gainwell Technologies' WV Medicaid and WVCHIP.  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 WV Medicaid and WVCHIP's Pharmacy Provider Help Desk at 1-888-483-0801.  The help desk nmumber for members is 1-888-483-0797.

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.
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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.