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Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

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.

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Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

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  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 Appeal Decision Reverses FHS’ Action: Prior Authorization Granted Pharmacy Dispenses Medication Finish Appeal Decision Remands Case to FHS for Additional Evaluation by Lead Clinical Pharmacist COMMONWEALTH of VIRGINIA Department of Medical Assistance Services

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