Physician Administered Drug Program Updates, Virginia Medicaid Drug Utilization Review Board Approved Updates and Preferred Drug List Effective October 1, 2026

REQUIREMENTS: By July 23, 2026: Billing team must identify which physician-administered drugs in your practice require service authorization under the new PAD program by consulting Appendix B: Physician Administered Drug Criteria at https://www.virginiamedicaidpharmacyservices.com/provider/authorizations. Update billing workflows to require SA submission before claims are submitted. Immediately: Establish fax submission process for SA requests to 804-452-5450 or mail to Virginia Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219. Ensure all SA requests include: (1) completed SA form, (2) all required drug-specific criteria, (3) clinical notes, and (4) clinical summary supporting medical necessity. Incomplete submissions will delay review. By October 1, 2026: Billing team must update PDL/CCF references in billing software and verify coverage status for all affected drug classes (estrogens, glucocorticoids, phenylketonuria treatments, bronchodilators, intranasal agents, antiemetics, HAE treatments, PAH agents). Consult the updated PDL at https://www.virginiamedicaidpharmacyservices.com/provider/preferred-drug-list to determine which drugs require SA versus pharmacy benefit routing. Before each claim submission: Verify provider enrollment in PRSS (Provider Services Solution) is current, including all service locations, license information, and contact details. Non-enrolled providers will have claims denied per federal rules. Ongoing: Monitor the Virginia Medicaid Pharmacy Services portal and email PhysicianAdministeredDrugs@dmas.virginia.gov for questions. Note that submission of documentation does NOT guarantee coverage—claims may still be denied.