WV Medicaid Announces Incidences Of Denying Opioid Rx


To Richard Stevens:  Beginning July 18, 2018, WV Medicaid is implementing a new policy which requires prescribers of opioid medication to be enrolled with WV Medicaid.  Please send the below communication to pharmacies.

Beginning Thursday, June 14 (Flag Day), WV Medicaid will implement Edit 7514 to FLAG all opioid prescriptions written by prescribers not enrolled with WV Medicaid.  The edit will be set to WARN until Wednesday, July 18, 2018, at which time the edit will DENY all opioid prescriptions written by unenrolled prescribers.

The return text for Edit 7514 is:  Drug Class Requires Prescriber Enrollment.  Contact Molina at 888-483-0801.   The Rational Drug Therapy Program (RDTP) will not be able to override this edit and the patient must find an enrolled prescriber.

The Medicaid and Molina staff are working to notify all Medicaid members and unenrolled perescribers about this policy.  Immediately below is notification for your Medicaid members.

Dear Medicaid Member:

On Wednesday, July 18, Medicaid will no longer pay for your prescriptions for pain that contain opioids, if the person prescribing your medicine is not enrolled with West Virginia Medicaid.  Medicaid will not override the denial at the pharmacy, and no exception will be made.

We are sending this letter to you because you have recently had opioid prescriptions filled that were written by a prescriber not enrolled with West Virginia Medicaid.  Some of the most common examples of opioids are:

  • Hydrocodone with Acetaminophen (Lortabs, Noro)
  • Oxycodone(Oxycontin)
  • Oxycodone with Acetaminophen (Percocet)
  • Fentanyl Patches
  • Tramadol
  • Morphine immediate release (IR) and morphine ER sustained release tablets
  • (This list does not include every opioid medication that will not be covered by un-enrolled prescribers)

Please show this letter to the person who writes these prescriptions for you.  If they choose not to enroll with West Virginia Medicaid, you will need to choose another health care provider who is enrolled in order for Medicaid to pay for these prescriptions.

On January 1, 2019, ALL prescriptions written for you by a person not enrolled with Medicaid will be denied at the pharmacy.

This is a Federal rule and your Medicaid pharmacy program must follow it.

If you cannot find a prescriber who is willing to enroll with West Virginia Medicaid and you are in a Managed Care Organization (MCO) plan, you can call the MCO Help Desk and ask them to help you find an enrolled healthcare provider.  The numbers to call are listed below:

  • Aetna 888-348-2922
  • Family Health Plan 855-412-8001
  • The Health Plan 800-624-6961
  • Unicare 800-782-0095

If you are not in a managed care plan (known as Fee for Service) you an call Molina Customer Help Desk at 888-483-0797 and ask them to help you locate an enrolled healthcare provider.