Prescribing and dispensing drugs in the virginia medicaid pdl program
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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
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


Prescribing and dispensing drugs in the virginia medicaid pdl program1
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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