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Pharmacy benefits

Need medication? Medicaid and Children’s Health Insurance Program (CHIP) pharmacy benefits include a wide range of prescription and over-the-counter (OTC) medications to keep you as healthy as you can be.

Questions?

You can call Member Services at 1-888-348-2922 (TTY: 711). We’re here for you 24 hours a day, 7 days a week­­­.

Medicaid pharmacy benefits

You have two categories of medications. And different groups manage your benefits for these medications:

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These are medications you get from a health care provider while you’re in: 
 

  • A doctor’s office

  • A hospital

  • An inpatient facility

  • An outpatient setting

  • At home

We manage your benefits for these medications.
 

Questions?

Talk with your primary care provider (PCP) or call us at 1-888-348-2922. Does your provider want you to have a medication that needs approval? They’ll work with us the same way they do for medical care that needs approval.

 

These are medications your doctor prescribes that you pick up later at the pharmacy. 

 

Gainwell Technologies manages your benefits for these medications. They are your pharmacy benefit manager (PBM). Check the medications they cover on the West Virginia Bureau for Medical Services Preferred Drug List (PDL).

 

Questions?
 

Call Gainwell Technologies at 1-888-483-0797.

Find a pharmacy

 

To find a CHIP or Medicaid pharmacy near you where you can pick up your outpatient medications:
 

  1. Visit WVMMIS Provider Search. 
  2. Go to “Type” and choose “Pharmacy.”
  3. Enter your location info. 

Pharmacy coverage decisions

Pharmacy coverage decisions

Some medications may need prior authorization (PA), or approval, before you receive them. Providers need permission to provide certain medications. They’ll know how to do this. And we’ll work together to make sure the medication is what you need.

 

Learn more about PA

Learn about our criteria for decisions
 

We use guidelines called criteria to make decisions about medical pharmaceuticals. This helps you get the right medication for your condition. The criteria we use may be from the state of West Virginia or other groups that make criteria for health plans.

Sometimes, the criteria:
 

  • Lists preferred medications for your condition

  • Requires you to try other medications first

  • Limits how much medication you can get

You and your doctor can get a copy of the criteria. You can also learn more about your medication coverage. Call us at 1-888-348-2922 (TTY: 711).
 

Learn how to ask for an exception
 

Sometimes members or providers ask us to consider a different medication than the criteria requires. You or your doctor can ask for an exception. Call us at 1-888-348-2922 (TTY: 711). Then, ask for the Utilization Management department.

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