Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

1
Prescribing and Dispensing Drugs in the Virginia
Medicaid PDL Program
Profiling/ Report Cards
Education
PDL Deployed Electronically
Dr. Chooses Preferred Drug?
Dr. Diagnoses Condition
Patient Visits Doctor
Start
Preferred Drug?
Dr. Writes Prescription
Patient Visits Pharmacy
Pharmacy Submits Claim
Yes
Yes
No
Proactive Prior Authorization Request
No
Data Analysis
Pharmacy Contacts Dr.s Office
Dr. Speaks with FHS Pharmacist, Lead Clinical
Pharmacist, or Physician
Medical Justification or Change?
Medical Justification or Change?
Dr.s Office Contacts FHS
No
Dr. Changes to Preferred Drug?
No
Yes
Yes
Yes
No
PA Granted
Pharmacy Calls FHS for 72-Hr Emergency Supply
Claim Adjudicated
Pharmacy Dispenses Medication
Finish
COMMONWEALTH of VIRGINIA Department of Medical
Assistance Services
2
Prescribing and Dispensing Drugs in the Virginia
Medicaid PDL Program
Profiling/ Report Cards
Education
PDL Deployed Electronically
Dr. Chooses Preferred Drug?
Dr. Diagnoses Condition
Patient Visits Doctor
Start
Preferred Drug?
Dr. Writes Prescription
Patient Visits Pharmacy
Pharmacy Submits Claim
Yes
Yes
No
Proactive Prior Authorization Request
No
Data Analysis
Pharmacy Contacts Dr.s Office
Dr. Speaks with FHS Lead Clinical Pharmacist or
Physician
Dr. Speaks with FHS Pharmacist
Medical Justification or Change?
Medical Justification or Change?
Medical Justification or Change?
Dr.s Office Contacts FHS
No
Dr. Changes to Preferred Drug?
No
No
Yes
Yes
Yes
Yes
No
No
PA Granted
Pharmacy Calls FHS for 72-Hr Emergency Supply
Letter Mailed to Dr. and Patient Outlining Right
of Appeal
Dr. and/or Patient Completes Appeal Paperwork and
Submits to DMAS Appeals Division
Appeals Hearing Conducted with FHS Staff
Assisting DMAS Appeals Division and Appearing at
Hearing
Claim Adjudicated
Appeal Decision Upholds FHS Action Patient
Returns to Dr. for Re-Evaluation of Drug Therapy
Pharmacy Dispenses Medication
Appeal Decision Reverses FHS Action Prior
Authorization Granted
Finish
Appeal Decision Remands Case to FHS for
Additional Evaluation by Lead Clinical Pharmacist
COMMONWEALTH of VIRGINIA Department of Medical
Assistance Services