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 | Menopur (menotropins), Follistim AQ (follitropin beta), Gonal-f/RFF (follitropin beta), Pregnyl, Novarel: Chorionic Gonadotropin (Human), Ovidrel (Chorionic Gonadotropin (Recombinant), Cetrotide (cetrorelix), Ganirelix, Lupron Depot (leuprolide acetate), Crinone 8% gel, Endometrin vaginal insert, progesterone | WV CAID CHIP-0015 | J9217, J0725, J1950, J3490, J8499, S0122, S0126, S0128, S0132 |
| Testosterone, Injectable | Azmiro, Depo-Testosterone (testosterone cypionate), Xyosted (testosterone enanthate), Aveed (testosterone undecanoate) | WV CAID CHIP-0026 | J1071, J1072, J3145, J3490, C9399 |
| Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Fensolvi (leuprolide acetate), Zoladex (goserelin acetate), Supprelin LA (histrelin acetate), Lupron Depot/Depot-Ped (leuprolide acetate), Synarel Nasal Spray (nafarelin acetate), Triptodur (triptorelin pamoate extended-release) | WV CAID CHIP-0061 | J1675, J3316, J9202, J9226, S9560, J1950, J1951, J9217, J9218, J1954 |
| Subcutaneous Hormonal Implants | Testopel (testosterone), estrogen containing implants | WV CAID CHIP -0008 | 11980, S0189, 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.