Welcome to the Clinical Criteria Page
This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the Provider notification process.
To determine if a code requires authorization, use the Pre-certification lookup tool
The West Virginia Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have West Virginia Medicaid State specific criteria. If a code requires authorization and the clinical criteria document is not found in the list below, please utilize the following link for additional criteria.Clinical Criteria
WEST VIRGINIA SPECIFIC POLICIES
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| HCG Agents | Menotropins: FSH and LH (Menopur), Follitropin and Urofollitropins: FSH (Follistim AQ, Gonal-f/ RFF), Human chorionic gonadotropins (hCG) Urinary-derived hCG (Pregnyl, Novarel and HCG generics) Recombinant hCG (Ovidrel), GnRH antagonists (Cetrorelix acetate (Cetrotide), Ganirelix), GnRH analogs or agonists (Lupron Depot® and generic leuprolide acetate), Clomiphene citrate, Progesterone vaginal supplementation or replacement (Crinone 8% gel, Endometrin vaginal inserts) | WV CAID CHIP-0015 | J1950, J3490 |
| Testosterone, Injectable | Testosterone cypionate intramuscular: Depo-Testosterone, generic testosterone cypionate, Testosterone enanthate Intramuscular: generic testosterone enanthate , Testerone enanthe Subcutaneous: Xyosted (auto-injector)], Testosterone undecanoate intramuscular: Aveed | WV CAID CHIP-0026 | J1071, J3121, J3145, J3490 |
| Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Fensolvi (leuprolide acetate), Lupron Depot, Lupron Depot-Ped (leuprolide acetate), Lupaneta Pack (leuprolide acetate for depot suspension and norethindrone acetate tablets), Supprelin LA 12 month implant (histrelin acetate), Synarel Nasal Spray (nafarelin acetate), Triptodur (triptorelin pamoate extended-release), Vantas (histrelin acetate), Zoladex (goserelin acetate) | WV CAID CHIP-0061 | J1675, J1950, J3315, J3316, J9225, J9226 |
| Subcutaneous Hormonal Implants | Testopel (testosterone subcutaneous implant) | WV CAID CHIP -0008 | J3490 |
(Note: in the case of a clinical criteria document being listed on both sites, please utilize those listed directly above.)
If you have questions or feedback, please contact druglist@carelon.com.