Prescription Formulary

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A formulary is a list of drugs our plan covers. The list includes prescription drugs and some over-the-counter drugs. To see which drugs are on the list, click on the links below.

Formulary Documents

Preferred Drug List

From the Bureau for Medical Services West Virginia Medicaid
Prior Authorization Criteria
From the Bureau for Medical Services West Virginia Medicaid
Additional Drug Formulary Information
Quantity Limits List (Drug Limitations)
The quantity limits list is provided by the Bureau for Medical Services. It is available at this link.
Specialty Drug List
PDF | 56 KB
17HP Provider Referral Form
Over-the-counter Medications Listed by Drug Category
PDF l 2.5 MB
List of over-the-counter medications covered under the plan, listed by drug category.
Claim Form
PDF | 87 KB
West Virginia Bureau of Medicaid Services
Information on the West Virginia Medicaid Pharmaceutical and Therapeutics Committee the Preferred Drug List
Pharmaceutical Management Procedures - Members
PDF | 80 KB
This document contains important information about how the formulary is developed, the process by which your provider can request a medication coverage exception, and additional pharmacy benefit information which is available online or by calling Customer Service.

Pharmacy & Therapeutics Committee Meeting Minutes

Coming soon.

Policies and Procedures

How to Access Your Pharmacy Benefit
PDF | 37 KB
Temporary Coverage Override (TCO)
PDF | 84 KB

Prior Authorization Forms


PDF | 755 KB
Atypical Antipsychotics for Children
PDF I 937 KB
Cox 2 Inhibitor
PFD I 882 KB
Diabetic Exception
PDF I 733 KB
Dose Titration
PDF I 102 KB
General Drug
PDF I 733 KB
Growth Hormone
PDF I 795 KB
Hepatitis C1A
PDF I 803 KB
Home Infusion
PDF I 742 KB
Preferred Drug List
PDF I 756 KB
Provigil Nuvigil
PDF I 796 KB
Quantity Limit

PDF I 175 KB
Suboxone Subutex
PDF I 507 KB
PDF I 824 KB
PDF I 797 KB
PDF I 504 KB
PDF I 756 KB

Prior Authorization Criteria

Prior Authorization Criteria
From the Bureau for Medical Services West Virginia Medicaid

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